Name

First Name

Last Name

How would you describe your skin?

Please tick all which apply

Sensitive

Normal

Dry

Dehydrated

Oily

Reactive

Combination

Mature

Congested

Uneven skin tone

Other (please provide details below)

Do you have any skin allergies? Have you ever had any negative reaction to any skincare product or treatment? *

Yes

No

Have you received any injection within the last 6 months? e.g. botox, collagen, hormonal support *

Yes

No

Acute Infectious Disease

Yes

No

Varicose Veins

Yes

No

Injury

Yes, In Neck

Yes, In Back

No

Jaw or Ear Pain

Yes, In Jaw

Yes, In Ear

No

Fainting or Dizziness

Yes, Fainting

Yes, Dizziness

No

Headaches or Migraines

Yes

No

Blood Pressure

High

Low

Normal

Skin Conditions

Yes

No

Fungal Infections

Yes

No

Nervous Disorders

Yes

No

Phlebitis / Circulatory Problems

Yes

No

Whiplash

Yes

No

Rheumatoid Arthritis

Yes

No

Osteoarthritus

Yes

No

Kidney Disease

Yes

No

Diabetes

Yes

No

Asthma / Respiratory

Yes

No

Fibromyalgia

Yes,

No

Crohn's Disease

Yes

No

Pelvic Inflammatory Disease

Yes

No

Epilepsy

Yes

No

Cancer

Yes

No

You confirm your understanding that i) Cancellations within 24 hrs incur a 50% charge ii) Treatment is not a replacement for medical care iii) we do not diagnose medical illness or any other physical or medical conditions and iv) we do not prescribe medicines. *

Yes

No

You confirm you have stated all known conditions *

Yes

No

You agree to advise us of any updates to the above. *

Yes

No

Please advise if you would like to join our mailing list for newsletters and updates

You can unsubscribe at any time and we will never pass your details on to anyone else.

Yes

No