Please find below a copy of the Client Consultation form you will be required to complete before your first treatment.
NAME:
DATE OF BIRTH:
ADDRESS:
PHONE:
EMAIL:
CONFIDENTIAL - please indicate YES or NO whether any of the following apply to you:
Are you currently receiving treatment from a doctor or other health care practitioner?
Are you taking any medication?
Recent scar tissue (within 6 months), bruises, cuts or grazes in the treatment area?
Any injuries or areas of tenderness to be avoided?
Urinary tract infections or STI's?
Skin disorders or infections (eczema, psoriasis, dermatitis, ringworm, warts, etc)?
Sunburn or heat allergies?
Easily bruised, sensitive or highly reactive skin?
Use of Roaccutane, Retin-A, Differin or other acne medication within the last 6 months?
Current use of glycolic acid or other AHA/BHA products?
Recent skin peel, dermabrasion, laser or IPL treatment?
Use of steroid creams or medication likely to cause thinning of the skin within the last 3 months?
Varicose veins or capillary damage in the treatment area?
Haemophilia?
Other circulatory disorders or heart conditions?
Diabetes?
Oedema or other swelling in the treatment area?
Nerve damage or increased/decreased sensitivity in the skin?
Epilepsy, fits or fainting attacks?
Allergies or intolerances (to sticking plasters, lanolin, essential oils, etc)?
Joint or mobility problems (arthritis, recent fractures, sprains, etc)?
Any other recent illnesses or conditions requiring medical treatment?
Have you ever received a ______________ treatment before?
"I
declare that the above information is true to the best of my knowledge
and belief. I have been informed about the expected results and effects
of my treatment, and agree to follow all aftercare instructions provided by
my therapist. I agree to the information on this form being stored by
my therapist and give my consent to proceed with treatment."
Signed:
Date:
