BEAUTY | pureessentialslondon

First name

Last name

Email

Phone

Birthday

Address

Doctors Name

GP Address

What type of treatment are you doing today?

Do you suffer from/have you suffered from the following (please tick all that apply)

Multi choice

Do you have any allergies to the following?

Multi choice

Please list any medications that you have taken or taking within the last 12 Months: (If non please write non)

Please list any medications that you have taken or are taking within the last 12 months:

Are you currently seeing your GP medica conditions?

Choose one

Yes

No

Have you ever seen a dermatologist?

Choose one

Yes

No

Have you had any operations in the last 12 months?

Choose one

Yes

No

Please Tick

I accept that any treatment i have is taken at my own risk. I certify that i have read and have completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility.

Please Tick

I fully understand the above and consent/permit the treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedures that is performed at my request.

Please Tick

I accept that if I am not satisfied with the treatment will inform the therapist and or request to speak to the manager immediately following the treatment.

Signature

Date