Consultation Form

Consultation Form

Please tell us a little bit about you so we can treat you to the best of our ability.
Your Full Name *
Date of Birth *
Suburb *

Street Address

Street Address Line 2
Postal/ Zip Code *

Street Address

Street Address Line 2
Phone Number
E-mail
Would you like to receive occasional the email update and our latest special offers? We promise we don't spam, it's not our style .

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I'm here because:

I want to relax I want tension relief I want information I have a gift voucher I want results
My body feels:

Fine, I would just like to relax Sore/ my movement is restricted Tense & tired
My pressure preference is:

Light Medium Firm
Please focus on (area):
Please avoid (area):
My skin feels:

Comfortable & Balanced Sensitive & irritated Dry & tight Flaky & Rough Oily & Bumpy
The following concerns me about my skin:

Breakouts/Acne Rosacea/eczema / dermatitis Uneven Tone Excessive oil / shine Black/White Heads Wrinkles / fine lines Sun damage Dull / dry
I currently use the following products:

Cleanser Day moisturiser Exfoliator Night moisturiser Toner Eye cream Serum Mask Make-up Sunscreen Shower gel Body lotion Soap Self-tan lotion
I'm currently using these skincare brands:
I'm also using:

Botox / Restylane / Collagen Retina-A / Renova / Adapalene / Hydroxyl Acid / Retinol / Vitamin A Acne medication
Before you start my treatment, you should probably know the following:
I regularly:

Exercise Stretch Receive professional Massage treatments See a Physiotherapist/ Chiropractor Perform repetitive movements at work/ sports/ or hobby
I have had allergic reactions to:

Cosmetics AHAs Medicine / drugs Fragrance Nuts Latex Sunscreens Iodine Animals Plants / Flowers
Do you have any difficulty laying on your front, side or back:

Yes No
I am, or there’s a chance I could be, pregnant:

Yes No
How many weeks?
I’m going through menopause or HRT:

Yes No
I have exfoliated my skin within 48 hours: (scrub or chemical)
I have been in the sun in the last 24 hours:
I have an illness or disease:
I am currently taking the following medication:
Is there anything else we should know about your overall health?
Are you comfortable with us documenting a part of your treatment for social media?

Yes No Yes, but please keep me anonymous
I’ve read and completed this form truthfully and to the best of my knowledge.
I understand withholding or providing the wrong information may result in irritation.
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