Consultation Form

    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:_______________________