LEANNE'S HEALTH & BEAUTY
CLIENT CONSULTATION FORM
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Town
County
Post Code
Email
*
example@example.com
Phone Number
*
Mobile Number
*
Date of Birth
-
Day
-
Month
Year
Date
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MEDICAL HISTORY
Do you suffer from any of the following? (please tick)
*
Allergies
Thyroid Problems
Headaches
High Blood Pressure
Low Blood Pressure
Heart Condition
Pace Maker
Varicose Veins
Eczema/Psoriasis
IBS/Bowel Problems
Arthritis / Rheumatism
Epilepsy
Claustrophobia
Asthma / Lung Problems Back Problems
Metal plates/pins
Diabetes
Muscular Pain
Anticoagulant therapy (blood thinning)
Roaccutane Treatment
Botox/Fillers
Recent Operations
Pregnancy
Other (please state below)
NONE OF THE ABOVE
Other
If you have ticked any of the above, please give details including date of vaccines:
Are you currently on any medication or under medical supervision? If yes, please give details:
Are you pregnant? Breast feeding? If yes, please give details?
I have read and understood the questions asked and confirm that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatments. I will update my therapist with any changes. I understand the salon has a Cancellation /No Show cancellation policy and that I will be charged 50% of a missed/cancelled appointment.
*
I AGREE
Signature
*
Date
*
-
Day
-
Month
Year
Date
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