Client Consultation Form || Lilys Beauty & Aesthetic

Date

Name

Surname

Address

Email

Telephone Number

Age

Dob

Sex

Do any of the following apply to you? Please Tick Mark

Heart Disease

Cancer

Hirsutism

Pacemaker

Gold Injections

Diabetes

Burns/Grafter Skin

Herpes (or cold sores)

Aids

Liver/Kidney Disease

Scars

Epilepsy

Port Wine Stain

Melanoma/Moles

Shingles

Haemangioma

Active Tan

Psoriasis

Polycystic Ovarian Syndrome

Anti-inflammatory medication

Haemophilia

Hormonal Imbalances

Acne

Vitiligo

Are You Currently being treated for a condition not listed? If yes, please state.

Have you had botox Treatment in the past 3 months? if so, please state where.

Are you currently taking medication? or contraception?

Have you ever used(or currently using) Retin A, Roaccutane or glycolic acid?

Have you had any laser treatment in the last 6 months?

Do you or have you suffered from any allergies?

Are you allergic to latex or vinyl?

Have you ever suffered an allergic reaction to topical numbing cream?

Doctors / GP's Name

Doctors / GP's Address

Telephone Number

Patient Name

Date

If you have answered yes to any of the above questions the practitioner reserves the right to refuse any treatment if they test you are unsuitable or request confirmation this is ok from your gp.

Client Consultation Form

Client Consultation Form

If you have answered yes to any of the above questions the practitioner reserves the right to refuse any treatment if they test you are unsuitable or request confirmation this is ok from your gp.

Before submitting the form, please check in with the shop staff. Otherwise, you will need to refill the form.