Treatment Consent Form

In order for us to tailor treatments especially for you and ensure your Therapist can give you the best possible care at all times, we appreciate you completing this form.

Consultation Form

Personal Details
Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address Town City Post Code
Phone*
Email*
Enter Email Confirm Email
Emergency Contact Details
Name*
First Last
Relationship to you*
Contact Number*
How did you find out about Rejuvenate?*
Existing and Previous Health Concerns
Please let us know if you have experienced any of the following:
Allergies?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Irregular skin pigmentation?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Coldsores / Herpes?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Diabetes?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Varicose veins?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
High or low blood pressure?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Epilepsy?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Hepatitis*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Easy Bruising?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Skin Condition / Abnormalities?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Heart Condition / Pacemaker?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Polysystic Ovarian Syndrome?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Metal Implants i.e IUD/Fillings/Pins?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Thrombosis / Phlebitis?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Cancer?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Surgery in the last 6 months?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Are you Pregnant?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Are you Breastfeeding?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Do you blush easily?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Any other condition not listed?*
- Yes
- No
If yes, explain further

(e.g what, when and if being treated etc)
Medication

Please list all medication you are currently / or have been taking over the last 6 weeks:
Consent
Covid-19 Medical Questions*
I Agree
You are required at this time to stay at home and self isolate if you have any of the following main symptoms of Corona Virus. Do you have a high temperature – this means you feel hot to touch on your chest or back.Do you have a new, continuous cough? – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)Do you have a loss or change to your sense of smell or taste? – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal.TO PROTECT OTHERS, PLEASE STAY AT HOME AND SELF ISOLATE FOR 10 DAYS IF YOU ANSWER YES TO ANY OF THESE QUESTIONS.Thank you for your co operation during this time.
Statement*
I Agree
I confirm the above statements are true, and that the therapist cannot accept responsibility for any injury I may suffer attributable to me not having given full and true answers to the above questions, and agree to all salon terms & conditions including courses bought, loyalty points used, special offers, treating underage clients and tint tests.*Vitamin A & retinol can contribute to skin sensitivity to waxing. Other contraindications to waxing could be hormonal changes and frequent waxing to the same area, especially eyebrows. Please inform us if you have ever experienced skin tearing from eyebrow waxing and note this can occur from time to time. We recommend hot wax to prevent tearing. YOUR PERSONAL DATA IS PROCESSED SO THAT WE CAN DO THE FOLLOWING: Collect specific personal data (name, address, email, contact number, DOB) that is required to enter into a contract to sell a product or service. Engage in communication with you including conformation and reminders of appointments, and requests to cancel or change bookings. Collect Health information to perform the agreed services appropriately, and potentially highlight areas that products and services may cause issues to clients because of their health. Ensure a safe service and provide industry standard advice. Select relevant offers, promotions and information for you. Estimate the number of customers we have. Hold personal data that is required by law or to respond to legal process. Hold for insurance purposes. Please see our Privacy Policy for full information.
Todays Date*
DD slash MM slash YYYY

Consultation Form

Personal Details

Emergency Contact Details

Existing and Previous Health Concerns

Consent

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