CONSENT 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…………………………………….