Consultation Form

Here at Butterfly and Rose Therapy we pride ourselves on delivering high quality treatments for affordable prices. It is essential that the right time and care is put into place to deliver satisfactory results whilst also adhering to guidelines to ensure client safety at all times.

Please copy and fill in the below consultation form and email  to butterflyandrosetherapy@gmail.com at least 24 hours prior to your appointment

    Where Beauty Begins Again                               

                                                        New Client Consultation Form

Name:____________________________________________________________

DOB:______________________________________________________________

Contact Number:________________________________________________

Emergency Contact Name:_____________________________________

Relation to you:_________________________________________________

Emergency Contact Number: __________________________________

1. What is your general health today?  Good  Average  Poor (Please State)__________________________________________________________________

2. Are you currently taking any medication?      Yes (Please State)   No

                  _____________________________________________________________________

3. Are you currently undergoing any surgeries or treatments? Yes (Please State)  No

                  _______________________________________________________________________

4. Have you had cancer within the past 6 months? Yes (Please State What & When) No

                 _________________________________________________________________________

5. Do you have any allergies?  Yes (Please state) No

           _________________________________________________________________________________

6. Do You Have Any Of The Following Skin Disorders?

• Psoriasis    

• Eczema

• Milia

• Dermatitis

• Acne

• Seborrhea

7. Do you have any of the following contraindications?

-Thrombosis  -Epilepsy  -Migraine  -Heart conditions  -Pregnancy

-Metal Implants  -Loss of skin sensation -Conjunctivitis   -Nausea

-Cancer  -Malignant Melanoma   -Dizziness  -Infectious Conditions Undiagnosed lumps and swelling  -Recent scar tissue  -Contagious skin disease  -Dysfunction of the nervous system

8. Do any of the following special care apply to you?

-Poor circulation   -Bruising  -Botox/fillers   -High/Low blood pressure

-Diabetes  -Cuts/ Abrasions  -Arthritis   -Asthma   -Recent Surgery

-Recent Injury  -Recent Surgery  -Swelling   -Sensitive Skin 

9. What is your stress level? (1 being low, 10 being high) 1  2  3  4  5  6  7  8  9  10

10. What are your treatment goals?

Some of the following contra-actions may occur:

-Erythema  -Allergic Reaction  -Migraine  -Bruising  -Bleeding

-Swelling  -Feeling faint  -Watery eyes  -Hyperaemia

Please provide some feedback of your treatment:

Client Signature:_______________________________________  Date:_______________________