Consultation Form
BUA BY DANIELA
Full Name
*
First Name
Last Name
GP DETAILS
GP Name
GP Address
Phone Number
*
-
Area Code
Phone Number
Address
First Line of address
Second Line of address
City/ Town
County
Post Code
Please tick those that apply to you:
*
Respiratory Conditions (Asthma)
Cancer
Cardiac disease
Diabetes
Epilepsy
Allergies
Eczema/Psoriasis
Pigmentation disorders
High or low blood pressure
Pregnancy
Severe skin conditions
Hypersensitive skin
Thyroid imbalances
Muscular disorders
Skeletal disorders
Claustrophobia
Watery eyes
Contact Lenses
Do you currently have any of the following:
*
Sunburn
Infections: Viral, Parasitic, Bacterial or fungal
Bruising
Eye infections
Cuts/ abrasions
Severe acne
Recent scar tissue
Fresh piercings
Fresh Botox or dermal filler
Undiagnosed lumps/Swelling/ Inflammation
Are you currently taking any medication?
*
Yes
No
If 'yes' please state below:
I confirm that to the best of my knowledge the information I have given is correct and I consent to it being stored according to the 'Data Protection Act 2018' for the purpose of my treatments and the safety of my wellbeing.
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