Name* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Select Your Treatments (Choose all that apply)* Threading Tinting Waxing Facial Massage Nails Lash Extension Slimming Treatments Henna Tattoos Your Age* Under 21 21-30 31-40 41-50 51-60 60+ Within the last year have you been under a dermatologist or other physician's care?* Yes No If yes, please specify Within the last nine months, have you undergone any surgery?* Yes No If yes, please specify Have you had any health problems in the past or present?* Yes No If yes, please specify Please list any medications, supplements, vitamins, diuretics, slimming tablets that you take regularly Do you smoke?* Yes No Do you exercise regularly (i.e. at least 2 times every week)* Yes No Do you follow a restricted diet?* Yes No Do you wear contact lenses?* Yes No Do you have metal implants, a pacemaker or body piercing?* Yes No Please rate your current stress levels 1=low stress, 4=high*1234Do you have any skin problems pertaining to your face or body?* Yes No Disclaimer* I accept that any treatment I have taken is at my own risk. I certify that i have read and 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 Disclaimer* I fully understand the above concent/permit and 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 procedure that is performed at my request. Disclaimer* I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager immediately following the treatment. Please print your name.* By printing your name here you acknowledge that this is an electronic signature.
