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Consultation Form

First name

Last name

Phone

Birthday

Day

Month

Year

Address

Emergency Contact Name + Telephone Number*

Do you currently. have any of the following? (Please tick if applicable)*

Pregnant or breastfeeding

Diabetes

Epliepsy

Heart Condition

High Blood Pressure

Skin Disorders (eczema, psoriasis etc)

None

Are you currently on any medication?*

If Yes, please list

How would you describe your skin type?*

Dry

Oily

Combination

Sensitive

Normal

Unsure

Do you currently experience any of the following?*

Acne or breakouts

Redness or irritation

Pigmentation

Fine lines or wrinkles

Sensitivity

None of the above

Have you ever had beauty treatments before?*

If yes, what treatments have you had?

Facials

Massages

Waxing

Lash or brow treatments

Skin treatments

Other

How many glasses of water do you drink per day?

Do you smoke?

How would you rate your stress levels?

Dropdown

Patch Test - this may be required prior to certain treatments. have you completed a patch test within the last 6 months?

I confirm that the information provided above is accurate to the best of my knowledge. I understand that certain treatments may not be suitable depending on my medical history and skin condition.

I agree to inform my therapist of any changes to my health before future treatments.

Date*

Day

Month

Year

Signature*

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Contact

07716 308 271

palmrootwellness@gmail.com

Unit 6 FF, Carr Ln, Hoylake, Wirral CH47 4AZ

Mobile - Wirral, Liverpool, Cheshire.

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