Consultation form

Choose a branch *

Name *

First

Last

Email *

Address

Phone number

Date of birth

Are you pregnant?

Please answer all of the questions, ticking as appropriate:

Please complete the section below only IF you intend to receive an eye treatment. Please tick if you have had any of the following:

Has a patch test been completed?

Date of patch test

Any signs of redness apparent?

Do you wear contact lenses

Any other allergies?

Have you undergone surgery in the last year

Are you on any medication

Within the last 6 months have you had any glycolic peels, laser treatment or injectable?

What is the main purpose of your visit

I have read and understood this consultation card and therefore give consent for my treatment *

A: 4 Upper Tachbrook street, London, SW1V 1SH

E: victoria@bellecourbeauty.com

A: 16 Melcombe Street, London, England, NW1 6AH

P: 02038186186 l M: 07342925660 (whatsapp)

E: bakerstreet@bellecourbeauty.com

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