Eve Taylor consent formClient D.O.BClient NameEmail AddressTelephoneChosen method of contactClient SignatureYour browser does not support e-Signature field.I acknowledge that on occasion it may be required that I am contacted regarding my appointments. I have read the Privacy Notice and give my consent for this.Health historyPlease list any serious illnesses you have experiencedPlease list any surgeries you have hadPlease list any medication you are currently takingDo you now or have ever smoked?YesNoDo you have metal implants, body piercing or pacemaker?YesNoDo you have any known allergies?YesNoAre you under a Doctor's care for any reason?YesNoAre you pregnant or planning a pregnancy?YesNoDo you experience claustrophobia?YesNoNutrition and lifestyleWhat percentage of your average daily diet is fresh food?What percentage of your average daily diet is processed food?How many of the following drinks do you consume on a daily basis?TeaWaterFizzy drinksAlcohol/Wine/BeerCoffeeHow often do you exercise?What is your favourite pass time?What is your current occupation?On a scale of 1-10 how do you rate your current stress level?Would you say your sleep patterns are:AdequateNot enoughPlentyHow much UV exposure do you have now and in the past?Your skinDo you ever experienceFlakinessTightnessRednessBreakoutsOily shineWhat is your specific concern about your skin?Is this ongoing or a temporary condition?What specific improvements do you wish to see?Have you ever received a salon/spa treatment before?YesNoWhat were the results?Skincare productsWhich brand of skincare are you using of the following on your face?CleanserExfoliantMasqueSerumTonerMoisturiserSPFMake-upOtherWhich brand of skincare are you using of the following on your body?CleanserExfoliantHair removalMoisturiserSPFOtherPrevious invasive treatmentsHave you ever had any of the following treatments, if so please mark the latest treatment date?BotoxDermal fillersChemical peelIPL / LaserFacial waxingMicro-dermabrasionQuestions to ask every visitAre you currently taking any prescription medication or under a doctors care?Have you recently exfoliated?Client SignatureYour browser does not support e-Signature field.I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I have read the Privacy Notice regarding the collection of health information and consent to my health information being processed for the purposes of determining the safety of treatments as described in the privacy notice. In addition to the health information provided, further information may be required for certain procedures. A full list of potential questions is available upon request.DateTreatment recordDateTreatment received / products usedTherapistI accept that any treatment I have taken is at my own risk. I certify that i have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility I fully understand the above concent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.Your browser does not support e-Signature field.Submit results
