07585929016 / 01296325196 info@myrachle.com 35 Merton Close, Berryfields, Aylesbury, Buckinghamshire, HP18 0ZN Opening Times 10am - 8pm
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)
Client Name * (required)
Address
Postcode
Contact Number *(required)
Mobile
Your Email * (required)
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
*(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.
