Consultation Form

Please fill out the following form.

First name

Last name

Email

Date of birth

Day

Month

Year

Full Address & Post Code

Use acne medication (oral/topical)

No

Yes

Do you use Retinols?

No

Yes

Do you use Alpha Hydroxy Acids?

No

Yes

Do you use Accutane?

No

Yes

Do you use Blood thinners?

No

Yes

Are you Diabetic?

No

Yes

Have you been waxed before?

No

Yes

Do you have Epilepsy?

No

Yes

Do you have any new scar tissues?

No

Yes

Are you pregnant?

No

Yes

Any undiagnosed lump or bumps?

No

Yes

Do you have Oedema?

No

Yes

Do you have Varicose Veins?

No

Yes

Do you have Psoriasis?

No

Yes

Do you have any skin disease?

No

Yes

Are you on any prescribed medication?

No

Yes

Do you have allergies?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Signature

Signature field is empty.

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