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Consultation & Consent Form
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Please ,insert your Name
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First
Last
Phone Number
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Please, insert your Email
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Address
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Have you any of the following
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Recent surgery
Alergies
Asthma
Epilepsy
Diabetis
Heart conditions
Skin disorders
Cancer
Pregnancy
In the last 6 months did you have - Fillers
In the last 6months did you have - Botox
Any medical condition that we should be aware
No, I do not have any medical condition that can reflect on the treatments
In reference to Covid- 19 ,Please onfirm all of the following
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I confirm ,I have no Covid -19 symthoms in the past 2 weeks ,nor contact with such people.
I will cancel my appointment if I have any fly or Covid sympthoms in order to protect the staff
Treatment Consent
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I give my permission for my therapist to carry out the treatment as we discussed ,and we have talked about any risks and concerns I may have .I have field this form honestly and truthfully .I will not hold my therapist liable for any adverse reactions to the treatment
I agree to receiving marketing and promotional materials
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