sb-salon.co.uk
07300040002
02381 22 87 86
Mon-Sat : 09.30-20:00 |
Sun : 11:00-18:00
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Consultation Form
Therapist
Date&Time
Treatment location
Personal Details:
Name
Address
Post code
Date Of Birth
Email:
Contact Number
Emergency Name
Emergency Contact Number
Please tick if you have any of the following health conditions
Pregnant
Aids/ Hiv
Cancer
Diabetes
Heart Problems
Hepatitis
High/Low Blood Pressure
Lupus
Recent Surgeries
Strokes
None of the Above
Additional information health conditions
What areas of concern do you leave regarding your skin?
Breakouts/Acne
Blackhead/Whiteheads:
Dull/Dry Skin
Excessive Oil/Shine
Wrinkles/Fine
Dehydrated
Rosacea
Broken Catillaries
Enlarged Pores
Uneven Skin Tone
Sun Damage
Flaky Skin
None of the Above
Is there any other information listed or not listed above / Surgery treatments/ any of the allergy I should know before beginning your treatment?
Are you currently using any of the following?
Retin A/Renova
Glycolic Acid/Alpha Hydroxy Acid Birth Control Pills
Hormone Replacement Therapy Hydroquinone
Topical Vitamin C Accutane
Sunscreen/ Sun Block
None Of The Above
Other
Are you using or have ever used any medications?
Acne
Cold Sores
Smoke
Had facials before
Tan
Electrolysis
Laser hair removal
Waxing (recently)
None Of The Above
Other
Are you currently using skin care products ?
Other-medications/additional infomation:
client sign
client sign Date
Guardian Sign
Guardian Sign date
Proof id client/Parent id
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It is your responsibility to inform Seema's Beauty Salon of any pre existing and all health conditions It is also your responsibility to inform Seema's Beauty Salon of any discomfort during/ after any session I understand and accept any risks of which I have been advised associated with the agreed upon skin treatment I release Seema's Beauty Salon from all liability arising from any injury and/or damage from failure to inform Seema's Beauty Salon of any pre-existing conditions, limitations, specific sensitivities, and/or any discomfort during/ after the treatment I agree to keep Seema's Beauty Salon updated as to any changes in my medical profile. if there is an issues with the treatments all client s must consultee/inform/ must come as soon as possible to Seema's beauty salon (in emergencies situation/ out of hour clients can / may contact doctors / hospital) if required
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