Client Consultation Form

    Consultation Form

    Please note this form must be kept for a minimum of 7 years for insurance purposes (all sections with a * need to be completed)

    Address

    Postcode

    Contact Number *(required)

    Mobile

    What communication would you like to receive from us?

    Appointment RemindersPromotions and OffersNewsletters
    Other

    How would you like to receive them?

    PhoneMobile/SMSEmailPost
    Other

    Doctor's name and address* (required):

    Previous treatments and reason for treatment.

    Medical History *(required)
    If any are marked yes, please go into more detail in the space under the condition.

    Heart conditions/Pacemaker
    YesNo

    Severe circulatory disorders/DVT
    YesNo

    Diabetes
    YesNo

    Skin disorder
    YesNo

    Kidney problems
    YesNo

    Swelling/oedema
    YesNo

    Haemophilia
    YesNo

    Cancer
    YesNo

    Limitation of body movement/arthritis
    YesNo

    Are you pregnant
    YesNo

    Epilepsy
    YesNo

    Prone to keloid scarring
    YesNo

    Hormone imbalance
    YesNo

    Stroke
    YesNo

    Claustrophobia
    YesNo

    Hepatitis
    YesNo

    Metal plates/pins/piercings
    YesNo

    Recent scar tissue/surgery
    YesNo

    Respitaratory problems
    YesNo

    Allergies
    YesNo

    High/low blood pressure
    YesNo

    Oprations within 6 months
    YesNo

    *Any other medical conditions/ailments
    YesNo

    Please specify

    Medication/treatments/aditional information

    Steroids
    YesNo

    Other medication
    YesNo

    Ultra violet exposure
    YesNo

    Retinol or Roaccutane
    YesNo

    Products containing fruit acids
    YesNo

    Microdermabrasion
    YesNo

    Laser/IPL
    YesNo

    Any other medications
    YesNo

    Please specify

    *(Required)
    Declaration I declare that the above information I have given concerning my health is correct.

    Signature *(Required)

    Date (YYYY-MM-DD)

    *Updates changes.
    Please provide us of any personal or medical changes applicable to this consultation form since your last treatment with us.
    Please fill up a new form if any changes applied to you and submit it.