Body, Skincare & Massage Consultation Card

First Name

Last Name

Date of Birth

Age

Phone

Email

Address & Postcode

Have you recently had surgery? YesNo

Do you take medication? YesNo

Do you now or have you ever smoked? YesNo

Do you have any known allergies? YesNo

Are you pregnant or planning a pregnancy? YesNo

Do you experience claustrophobia? YesNo

How many of the following drinks do you consume daily?
Coffee: Tea: Fizzy Drinks: Water: Alcohol/wine/beer:

How often do you exercise?

What is your current occupation?

On a scale of 1-10 how do you rate your current stress level?

How would you say your sleep patterns are? AdequateNot enoughPlenty

How much UV exposure do you have now and in the past? Less than averageAverageMore than average

Do you ever experience: FlakinessTightnessRednessBreakoutsOily Shine

What is your specific concern about your skin?

What improvements do you wish to see?

Which of the following products do you use?
CleanserExfoliantMasqueSerumTonerMoisturiserSPFMake-upOther

If you have had any of the following treatments, please enter the date of the latest relevant treatment:
Botox:
Dermal fillers:
Chemical peel:
IPL/Laser:
Micro-Dermabrasion:

I have read, understood and agree with the before/after care instructions: Yes

I have read, understood and agree with the COVID-19 Policy Yes

I have read, understood and agree with the Terms & Conditions Yes

I have read, understood and agree with the GDPR Privacy Policy

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