Consultation Form Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address City Postcode Phone(Required)Email(Required) Do you suffer from any allergies?(Required) Yes No Please specifyDo you wish to receive special offers via email? Yes No Having a Facial? What is your skin like? Sensitive Dry Oily Combination Dark Circles Acne Have you had a recent (within 6 months) chemical peel/laser/microdermabrasion treatment? Yes No Have you had a recent Botox/Lash Extension/Lip Filler treatment? Yes No Do you currently have any of the following conditions? Cancer Muscular problems Infectious diseases Thrombosis/varicose veins Diabetes Epilepsy Joint problems Heart conditions Fungal conditions Skin disorders Recent vut/abrasion/bruising/swelling/inflamation Fatigue Unstable blood pressure Depression Insomnia Other: Please specifyWithin the past 14 days have you had any symptoms of Covid-10? Yes No Coughing, temperature, loss of taste and smellIf you have answered yes, please provide details Use of own couch/massage table? Yes No Declaration“I the undersigned have completed the form as fully and accurately as I can. I believe the details to be correct and consent to having treatment with the practitioner detailed on this form. I release the practitioner from any negligent misrepresentation that may be contained in this form.”SignatureName First Last Date MM slash DD slash YYYY