CONSULTATION FORM - CLIENT RECORD CARD Name * First Name Last Name Email * Street: Town: Postcode: * Telephone Number: Date of Birth General Practitioner: * Address and Phone number: What communications would you like to receive from us? Appointment Reminders Promotions and Offer Newsletters Others If others, please specify How would you like to receive them? Phone Mobile SMS Email Post Other If other, please specify Previous treatments and reason for treatment * Medical History * If any are checked, please go into more detail in space provided below Heart conditions/pacemaker Severe circulatory disorders/DVT Diabetes Skin disorders Kidney problems Swelling/oedema Haemophilia Cancer Limitations of body movement/arthritis Are you Pregnant Epilepsy Prone to keloid scarring Hormone imbalance Stroke Claustrophobia Hepatitis Metal plates/pins/piercings Recent scar tissue/surgery Respiratory problems Allergies High/low blood pressure Operations within 6 months N/A Please elaborate or specify any other medical conditions/ailments * Medication/Treatments/additional information * Steroids Retinol or Roaccutane Other medication Products containing fruit acids Ultra violet exposure Microdermabrasion Another other medications N/A Please Specify: Declaration: I declare that the above information I have given concerning my health is correct * Please insert name below to indicate you agree with declaration Date: * DD/MM/YY Thank you!
