First name

Last name

Address

Postcode

Phone


Your primary contact number

Your email

Intake date

Date of Birth

Health History

Heart Condition

Lymph Oedema

Herpes/Shingles

Diabetes

Low Blood Pressure

Blood Clots

Sprains/ Strains

Broken/Fractured Bones

Arthritis

Cancer

If you are pregnant, how many weeks?

Other (please explain)

Skin Care

Are you under the care of a Dermatologist?YesNo

Do you use any prescription skin products?YesNo

Have you had a:Chemical PeelBotoxMicrodermabrasionOther skin resurfacing treatmentsNone

Do you have any skin sensitivities or irritants?YesNo

Notes

I agree that all information is correct and by ticking this box and entering my full name below I give permission for the treament to be given

I accept that any treatment I have taken is at my own risk. I certify that i have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility

Disclaimer
I fully understand the above concent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.