CONSENT FORM

CONSULTATION FORM

NAME…………………………………………………………………………………… DATE OF BIRTH…………………

ADDRESS…………………………………………………………………………………………………………………………..

POSTCODE…………………………………………………. EMAIL………………………………………………………….

TELEPHONE NUMBER……………………………………………………………………………………………………….

MEDICAL HISTORY

Have you got any allergies?    YES/NO

DETAILS……………………………………………………………………………………………………………

Have you ever had an allergic reaction to any of the following?       

 YESNODETAILS
TINT   
WAX   
LATEX/PLASTERS   
MASSAGE OILS   
PERM   
LASH GLUE   
ASPIRIN   

Are you currently taking any medication?

YESNODETAILS
HORMONES
WARFARIN
CANCER TREATMENT
ROACCUTANE
BIRTH CONTROL
SKIN TOPICALS   
HERBALS   
OTHER   

Do you have any of the following?

YESNODETAILS
CANCER
EPILEPSY
HERPES
SEIZURES / DISORDERS
DIABETES
AIDS/HIV
HIGH/LOW BLOOD PRESSURE
HEART PROBLEMS

Do you have any other health problems or medical conditions?

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

I can confirm I have had a patch test and that I have had no reactions and that I am happy for my treatment to be carried out.

SIGNED…………………………………………………………………………..DATE………………………..………….

I certify that the above information is true and correct to the best of my knowledge. I am aware that it is my responsibility to inform my therapist of any changes that occur.

SIGNED…………………………………………………………………………..DATE…………………………………….

I give permission for ………………………………………………… To use any photos or videos taken during treatment on their social media platforms and websites for advertising purposes.

SIGNED…………………………………………………………………………..DATE…………………………………….