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Consultation Form

Fields marked with an * are required

All information contained here is strictly confidential and for Salon use only.

Tick this box if you want to hear about future promotions /offers

Health & Lifestyle

Within the last year have you been under a Dermatologist or Doctors Care?
Have you had any Health Problems in the past or present?
Is there any area of the Body where you are experiencing tension, stiffness, pain, or other discomfort?
Do you experience stress in your work, family, or other aspects of your life?
Rate your stress level 1-5 (1 being low 5 being high)
If yes how do you think it has affected your health? (Please tick)
Do you see a chiropractor?
Have you ever experienced a severe Skin Reaction i.e. hives, prickly heat, cellulites?
Are you pregnant or currently trying to become pregnant?
Do you smoke?
Do you wear Contact Lenses?
Do you Sunbathe or use Tanning Beds?
Have you ever experienced Claustrophobia?
Do you drink more than 4 caffeinated beverages daily (tea, coffee, soft drinks)?
What is your preferred massage pressure?
What skin care are you currently using on your face?
What skin care are you currently using on your body?
Do you have any allergies to the following?
Do you use Retin A, Renoua, Roaccutane, Adapalene or any other prescription skin products?
Do you consider your skin sensitive?
Have you had any of the following advanced clinical treatments within the last month?
Are you currently using any products that contain the following Ingredients?
Do you use SPF daily?
Do you ever experience any of the following conditions on your Skin?
Please tick if you suffer from any of the following?
Contra-Indications requiring medical permission for some treatments in circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to treatment. Subject to approval.
Contra- Indications that restrict certain Treatments. Select where appropriate.

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