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.

Name *

First

Last

Email *

Email

Confirm Email

Please ensure that your email address is correct.

Mobile Telephone Number *

Please provide us with your Mobile Number to enable us to send a Reminder Text Message for your appointment.

Home Phone Number

Please provide us with your Home Phone Number.

Date of Birth *

Please provide us with your Date of Birth.

Address *

Address Line 2 *

Town *

County

Postcode *

Medical History

• Aesthetic Treatments
• Active Cold Sores
• Anti-depressants
• Asthma/Breathing Difficulties
• Botox/ Collagen/Fillers
• Cancer (any form)
• Cosmetic Light-based Treatments
• Diabetes
• Epilepsy
• Headaches/Migraine
• Heart Condition
• High/Low Blood Pressure
• Highly Sensitive/Delicate Skin
• Hormone Irregularities
• HRT
• IBS or other Bowel Conditions
• Inflammation/Infection
• Kidney Related Problems
• Major Operations
• Metal Implant/Body Piercings
• Multiple Sclerosis
• Moles
• Over/Under-Active Thyroid
• Pacemaker
• Pregnancy (Please provide Due Date)
• Prosthesis/Silicone Implant
• Recent Operations
• Retin A/Roaccutane
• Semi-Permanent Make-up
• Severe/Active Acne
• Severe Muscle Conditions
• Skin Conditions
• Skin Lesions
• Sunbathe/Tanning Beds
• Thrombosis/Phlebitis
• Tumours
• Varicose Veins

Please select all options that are applicable and provide any further information in the box below.

Medical History Notes

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.

Doctor's Name *

Please provide the Name of your General Practitioner.

Doctor's Address *

Please provide the Surgery Name and Address of your General Practitioner.

Doctor's Telephone Number *

Please provide the Telephone Number for your General Practitioner.

Medical Supervision *

Please provide details of any condition you are currently under Medical Supervision for. Please state "None" if that is the case.

Medication *

Please provide details of any Medication or Supplement you are currently Taking. Please state "None" if that is the case.

Allergies *

Please provide details of any Allergies you suffer from. Please state "None" if that is the case.

Skin Overview

Please provide us with a brief overview of your skin and any concerns you currently have,

Skincare Products

• Cleanser
• Exfoliant
• Eye Treatment
• Mask
• Moisturiser
• Serum
• Toner
• Soap and/or Water

Please let us know if you use any of the skincare products listed.

Confirmation Statment

• I confirm the following:

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.
   

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