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Home
Services
About Us
Contact us

Book A Consultation

Home
Services
About Us
Contact us

Home
Services
About Us
Contact us

Book A Consultation

Home
Services
About Us
Contact us

First Name

Last Name

Email *

Phone *

Street Address

Postal code

Please Answer The Questions Below:

How did you hear about us?

Would you like to be added to our email list for specials and discounts?

Yes

Medical History:
Do you have or had any of these following conditions? If yes please check below

Diabetes

Epilepsy

Oedema

Phlebitis

Hypersensitive Skin

Varicose Vein

Psoriasis

Poor Circulation

Sunburn

Moles

Skin Disease

Pregnancy

Prescribed Medicine

New Scar Tissue

Any other conditions, Please Explain:

Any Known Allergies?

Yes

Allergy Type:

List Any medication you take regularly including vitamins, herbal supplements, aspirin:

Any Recent Surgery Including Plastic Surgery?

Yes

Are you pregnant or trying to be pregnant?

Yes

Do you smoke or drink Alcohol?

Yes

Other:

By submitting below, you agree to the following:
I have completed this form truthfully and to the best of my knowledge. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misinterpretation of my health history

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