Consultation Form

No
Yes
Trying
Lactating
Hyperthyroid
Heart Condition
Eczema
Psoriasis
Depression
Vericose veins
Headaches
Astama Epilipsy
Epilipsy
Claustrophobia
Arthritis
Cellulite
Water Retention
Migraines
Metal Implants
Iodine Allergy
Poor Circulation
Constipation
Seafood Allergy
Low/High blood pressure
Rheumatism

Please complete this section only IF you intend to receive an eye treatment

Cataract
Alpecia
Glaucoma
Eczema
Conjunctivitis
Sensitive eyes
Diabetic retiopathy
Allergy to latex
Trichotillomania
Recent eye infection
Dry eye syndrome
Wear contact lenses
Allergy to medical tape/plasters
Psoriasis around eye

Patch test

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

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