Health Questionnaire

1
Personal Details
2
Address
3
Health Questions
4
Consent
Title *
First Name *
Surname *
Email *
Phone Number *
Date of Birth *
Please fill in your personal details before proceeding.
Address Line 1 *
Address Line 2 (Optional)
City *
County *
Postcode *
Country *
Please fill in your address details.
Health Conditions
Do you have any allergies? *
Please provide details of your allergies
Do you have any skin conditions? *
Please provide details of your skin conditions
Are you taking any medication? *
Please provide details of your medication
Are you booking in for a facial treatment? *
What is your skin type? *
What is your secondary skin concern? *
What is your primary skin concern? *
Let us know your sensitive skin symptoms: *
Please provide more info:
How do you currently take care of your skin?
Are you pregnant? *
When is your due date?
How many times do you shave your face per week (if applicable)
If any, specify your skin concerns related to shaving:
Recent Treatments & Conditions (Select all that apply - doctors release form required)
Do you suffer from chronic tendonitis? *
Do you have metal plates implanted in your body? *
Have you been diagnosed with heart disease? *
Do you suffer from an inflammatory skin disease? (e.g. Herpes, melanoma, carcinoma, lymphoma) *
Do you suffer from high blood pressure? *
Do you suffer from epilepsy? *
Do you suffer from fibromyalgia? *
Have you had Botox and/or hyaluronic acid injections or filler in the last month? *
Any additional notes?
Please fill in all required fields.
Please confirm which salon you would like to attend. *
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