Client Consultation Form

Client Consultation Form

Please complete the consultation form below prior to attending your appointment in order that we should have all of the relevant information in order to carry out your treatments.

Please ensure that your email address is correct.
Please provide us with your Mobile Number to enable us to send a Reminder Text Message for your appointment.
Please provide us with your Home Phone Number.
Please provide us with your Date of Birth.
Please select all options that are applicable and provide any further information in the box below.
Please provide any further information that could be relevant to the conditions you have indicated or any additional information we would need to safely carry out your treatments.
Please provide the Name of your General Practitioner.
Please provide the Surgery Name and Address of your General Practitioner.
Please provide the Telephone Number for your General Practitioner.
Please provide details of any condition you are currently under Medical Supervision for. Please state "None" if that is the case.
Please provide details of any Medication or Supplement you are currently Taking. Please state "None" if that is the case.
Please provide details of any Allergies you suffer from. Please state "None" if that is the case.
Please provide us with a brief overview of your skin and any concerns you currently have,
Please let us know if you use any of the skincare products listed.

  1. All of the information I have provided is accurate to the best of my knowledge.

  2. I have not withheld any known medical condition or history that could be relevant.