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Client Consultation FormRich Cooper2021-04-16T08:01:47+01:00

Client Name *

Address *

Postcode

Date of Birth *

Phone Number *

What communications would you like to receive from us?

Appointment Reminders

Promotions & Offers

Newsletters

How would you like to receive them?

Text

Post

Medical Details & History

Doctors Name *

Doctors Address *

Previous treatments and reason for treatment

Conditions

Should any of the below conditions be checked, please use the additional box to elaborate.

Heart conditions/Pacemaker

Severe Circulatory Disorders

Diabetes

Skin Disorders

Kidney Problems

Swelling/Oedema

Haemophilia

Cancer

Limitation of body movement/arthritis

Are you Pregnant?

Epilepsy

Prone to Keloid Scarring

Hormone Imbalance

Stroke

Claustrophobia

Hepatatis

Metal Plates/Piercings/Pins

Recent Scare Tissue Surgery

Respiratory Problems

Allergies

High/Low Blood Pressure

Operations within Six Months

Other medical conditions/ailments

Medication | Treatments | Additional Information

Steroids

Other Medication

Ultra Violet Exposure

Retinol or Roaccutane

Products Containing Fruit Acids

Microdermabraison

Laser/IPL

Other - Please Specifiy

COVID-19

COVID-19 symptoms include fever, shortness of breath and coughing

Have you recently been ill?

Do you follow recommended hygienic practices? From washing hands thoroughly for 20 seconds, maintaining social distancing and wearing face masks ?

Have you come in contact with anyone who tested positive for COVID-19?

Have you done any at-home treatments?

Do you have a well-vented workspace outside of your home or inside ?

Oncology ?

If you are having an Oncology treatment please complete the below

Have you any hot seeds (active radioactice implants - in which case all touch therapies are contraindicated).

Have you received an infusion of the following drugs within the last 18-24 hours.

Thiotepa

Methoxotrate

Cytosine

Cyclophosphamide (CP)

Cytoxan

If the answer to the Oncology question is 'yes' please shower before the touch therapy, or return after 24 hours post infusion.

Declaration

When submitting this form I declare that the above information I have given concerning my health is correct

Updates | Changes

Please advise us of any personal or medical changes applicable to this consultation form since your last treatment with us? Please resubmit stating reasons..

Thank You for submitting our Consultation Form. It has been sent.

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Conscious of our environmental footprint, Perfect Mini Spas boutique offers a collection of ethically sourced, natural and organic products. We are also great advocates of the ever increasing focus on sustainability and understand our responsibility as part of this which is why we will also look to give back with contributions most notably to Plastic Oceans UK, but also The Mind Charity and Cancer Research UK

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