Lorraine\'s Treatment Room Client Consultation Form | Webform Portal

Personal & Contact Information

Surname *

First Name *

Preferred contact number *

Date of birth *

Postal Address *

Email address *

Post code *

Emergency Contact Name *

Emergency Contact Number *

Health History - This section is mandatory, thank-you for providing this information

Are you under a medical professional's care for any reason? *

If yes, please provide more information or write N/A *

Are you currently taking any medication, supplements, or vitamins? *

If yes, please provide more information or write N/A *

Have you suffered a serious illness or surgery in the past 10 years? *

If yes, please provide more information or write N/A *

Do you have any allergies or intolerances? *

If yes, please provide details of your allergy/ies or intolerances *

If yes, please provide details of your allergy/ies or intolerances

Do you presently or have you ever smoked? *

Are you presently pregnant or trying to conceive? *

If you are pregnant, what is your EDD? (Or N/A) *

If you are pregnant, what is your EDD?

Have you had a baby in the past three months? *

Do you have your medical professional's permission to have a massage? *

Do you have any metal implants, a pacemaker, or body piercings? *

Please provide additional details- or N/A *

Please provide additional details

Do you suffer with claustrophobia? *

Do you have blood pressure issues? *

Please provide futher details and how this is controlled. *

Please provide futher details and how this is controlled.

Do you have a heart condition? *

Please provide further details and how this is controlled. *

Please provide further details and how this is controlled.

Do you have epilepsy or prone to fits? *

Do you have history of thrombosis? *

Please provide further details

Do you suffer from any nervous disorders? *

Do you have any skin disorders or infectious conditions or diseases? *

Could you kindly provide further details *

Could you kindly provide further details

Do you bruise easily? *

Do you have varicose veins? *

Do you suffer from swelling or oedema? *

Could you kindly provide further details

Have you ever had or do you presently have cancer / skin cancer / auto-immune problems? *

Could you kindly provide further details about your treatment and, if you are in remission, how long this has been *

Could you kindly provide further details about your treatment and, if you are in remission, how long this has been

Are you diabetic? *

Are you haemophiliac? *

Do you suffer with porphyria? *

Do you have lupus? *

Do you have osteoporosis? *

Do you have arthritis? *

Please provide further information *

Do you suffer from skeletal problems? *

Please provide further details *

Please provide further details

Do you get frequent headaches / migraines? *

Do you use, or have you used within past 6 months AHA/BHA products, steroid creams / medication, or Roaccutane / other acne products? *

Please provide further details *

Please provide further details

So you suffer from any skin pigmentation conditions such as hyperpigmentation, moles, spider naevi, etc? *

Could you please provide further details *

Could you please provide further details

Do you have PCOS or any other hormonal imbalance? *

Could you please provide further details including how this is controlled *

Could you please provide further details including how this is controlled

Do you have any problems / medical conditions relating to your eyes? *

Could you please provide further details including how this is controlled *

Could you please provide further details including how this is controlled

Is there anything else you would like me to be aware of? Anything that you think may affect your treatment? *

Anything else you would like to tell me about?

Please provide further relevant information here

Nutrition & Lifestyle

What percentage of your average daily diet is fresh food?

What percentage of your average daily diet is processed food?

Do you follow a restricted diet?

If yes, please give more details

How many of the following drinks do you consume daily

Water / Tea / Coffee / Fizzy Drinks / Alcohol

What is your current occupation

How often do you exercise?

What do you do to relax?

How would you rate your stress levels?

How would you describe your sleep pattern?

How much UV exposure do you have on average?

Data Protection

I am committed to protecting your privacy.

I take special precautions with your sensitive personal data and will process your data lawfully and as described.

I only process the data we need for as long as we need to and respect all of your rights under GDPR.

I will never sell, share or otherwise abuse your data.

You can contact me at anytime to request your data or change your preferences.

To comply with industry standards, your personal details and treatment details are kept for a period of seven years.

GDPR is the European privacy law designed to protect you and give you control of your data.

Consent

I, the client, have given honest and comprehensive answers to all the questions asked on this consultation form. I understand that if I have been untruthful with my details or have failed to give enough relevant information the outcome of any therapy or treatment could be adversely affected and my health and well-being may be put at risk.

I understand the therapist/practitioner does not claim to cure or to diagnose any medical condition. Their opinion is that of a beauty, holistic, complementary and alternative therapist. Any advice or recommendations do NOT constitute the medical advice of a doctor/physician.

I confirm that I have given my personal details for the therapist’s/practitioner’s use in connection with the therapy or treatment I have booked now or in the future. I consent to the storage of these details in accordance with their professional association's guidelines.. I understand that therapy or treatments are unable to be provided without my consent.

I confirm that you may retain this information so that you can contact me again in the future.

I fully understand that the effects of treatments are cumulative. I understand that treatment is not a substitute for medical advice and it may take several sessions before I notice any benefit of the treatment/s given. I understand my life style, ongoing medication and general health may have an effect on the efficacy of any treatments.

I confirm that all the information I have given on this form is accurate to the best of my knowledge and I will ensure that I advise my therapist of any changes.

I agree with the above consent statments. *

yes no

Signature *

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