Client Consultation Form

Client Consultation Form

Please complete prior to your appointment
All information is confidential and used for your safety
Full Name

First NameLast Name
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Contact Number
Is it your first visit to Zoe's Retreat? *Returning clients if you have not previously completed a digital consultation with us from July 2026 please select yes to complete all sections of the form.
Have there been any changes to your health since your last vist?
please list the changes
Have you developed any new allergies
please list changes in allergies
Email Address
example@example.com
Emergency Contact details

Emergency Contact NameContact Number
Please tick any that apply
Medical Conditions

Other
Have you ever had/currently experiencing:

Other
please provide further details
Are you currently taking any medication?
Please list medications
Are you currently using, or have you used in the last 6 months, any vitamin A or Retinoid products or medication (eg Roacctune/ Isotertinoin, tretinoin, Adapalene or Retinol)?
Please provide details, including the name of the medication or product, how often you use it, and when you last used it
Are you pregnant?
Are you breastfeeding?
Do you wear contact lenses?
Do you have any allergies?
please list allergies
Where did you hear about us?

Other
I understand that, where clinically necessary, photographs may be taken before, during and/or after treatment for the purposes of treatment planning, treatment records, monitoring results, insurance requirements and the protection of both the client and Zoe’s Retreat. These images will be stored securely as part of my client record and will not be used for marketing purposes without my separate consent.
Marketing & Social Media Consent (Optional)
I confirm that I have provided accurate and complete information regarding my health, medications, allergies and medical history. I understand that all treatments carry inherent risks and that individual results and reactions may vary. Whilst every reasonable care will be taken during my treatment, no guarantee has been made regarding treatment outcomes. I agree to follow all pre-treatment and aftercare advice provided. I understand that failure to do so may affect treatment results and may increase the risk of adverse reactions. I understand that Zoe’s Retreat and its therapists cannot be held responsible for adverse outcomes arising from inaccurate, incomplete or undisclosed information provided by me, or from failure to follow recommended aftercare advice. I agree to inform Zoe’s Retreat of any future changes to my health, medications, allergies, pregnancy status or other relevant medical circumstances prior to treatment.
I have read and understood the above information and consent the treatment being carried out.
Signature
Date First Name Last Name
Should be Empty: