Home
Book online
Medical consult - Form
Massages /Gift cards
Facials /Gift Cards
Terms & Conditions
Medical Consultation Form
*
Indicates required field
Please ,insert your Name
*
First
Last
date of birth
*
Phone Number
*
Email
*
Gender
*
Male
Female
Neutral
Occupation
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Have you any of the following
*
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
High blood pressure
Osteoporosis
No, I do not have any medical condition that can reflect on the treatments
Do you have any medical condition or take any medication that we should be aware and might reflect your treatments?
*
In reference to Covid- 19 ,Please confirm all of the following
*
I confirm ,I have no Covid -19 symptoms in the past 2 weeks ,nor contact with such people.
I will cancel my appointment if I have any fly or Covid symptoms in order to protect the staff
Treatment Consent
*
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 give permission a photos of my treatment or treatment arias to be used for advertising and monitoring purposes.
I agree to receiving marketing and promotional materials
Submit
Aftercare Treatment Forms
eyelashes_aftercare.docx
File Size:
12 kb
File Type:
docx
Download File
after_care_advice_led_treatment.docx
File Size:
12 kb
File Type:
docx
Download File
dermabrasion_after_care.docx
File Size:
13 kb
File Type:
docx
Download File
after_care_rf_skin_tightening_treatment.docx
File Size:
13 kb
File Type:
docx
Download File
Home
Book online
Medical consult - Form
Massages /Gift cards
Facials /Gift Cards
Terms & Conditions
