Treatment Consultation Form

Name*

First Last

Phone*

Email*

Health Check Questionnaire completed?*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Doctors Name and Address*

Medical History - please tick all conditions that are relevant to you*

Medication and Treatments - please tick all those applicable*

Steroids
Retinol / Roaccutane
Laser / IPL
Botox
Products containing Fruit Acids
Ultra Violet Exposure
Microdermabrasion
None of the above
Other - please detail below

Any other medical conditions, allergies or ailments or any medical history that may effect your treatment?*

Any other medication or treatment that may effect your treatment?*

What is your current skincare routine? (For Facial Treatments only - please enter N/A if you are booked for a Massage Treatment)*

What are your main skin concerns? (For Facial Treatments only - please enter N/A if you are booked for a Massage Treatment)*

How would you like your skin to feel? (For Facial Treatments only - please enter N/A if you are booked for a Massage Treatment)*

DECLARATION - I confirm that the information provided by me is correct, knowing that this is relied upon to plan safe treatments. I will inform Claire Bowring if there is any change to my condition or health. I agree that Claire Bowring will not be held responsible for any injury by not giving full and true information.

I confirm and agree

Phone

This field is for validation purposes and should be left unchanged.

Treatment Consultation Form

Facial & Massage Treatments