Terms & Conditions
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Consultation Form
Choose the Branch
Select
Victoria
Westminster
Kensington
Name *
Address
Tel *
Date of Birth
Email address *
Occupation
Hobbies/Sports
Are you pregnant?
No
Yes
Trying
Lactating
Please answer all of the questions, ticking as appropriate:
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
Please tick if you have had any of the following:
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
Has a patch test been completed?
No
Yes
Date of patch test
Any signs of redness apparent?
Do you wear contact lenses?
No
Yes
Any other allergies?
Have you had 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
Please e-sign in the box below *
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