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

CityState / Province
Postal/ Zip Code*

Street Address

Street Address Line 2

CityState / Province
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 relaxI want tension reliefI want informationI have a gift voucherI want resultsOther
My body feels:

Fine, I would just like to relaxSore/ my movement is restrictedTense & tiredOther
My pressure preference is:

LightMediumFirm
Please focus on (area):
Please avoid (area):
My skin feels:

Comfortable & BalancedSensitive & irritatedDry & tightFlaky & RoughOily & BumpyOther
The following concerns me about my skin:

Breakouts/AcneRosacea/eczema / dermatitisUneven ToneExcessive oil / shineBlack/White HeadsWrinkles / fine linesSun damageDull / dryOther
I currently use the following products:

CleanserDay moisturiserExfoliatorNight moisturiserTonerEye creamSerumMaskMake-upSunscreenShower gelBody lotionSoapSelf-tan lotionOther
I'm currently using these skincare brands:
I'm also using:

Botox / Restylane / CollagenRetina-A / Renova / Adapalene / Hydroxyl Acid / Retinol / Vitamin AAcne medicationOther
Before you start my treatment, you should probably know the following:
I regularly:

ExerciseStretchReceive professional Massage treatmentsSee a Physiotherapist/ ChiropractorPerform repetitive movements at work/ sports/ or hobby
I have had allergic reactions to:

CosmeticsAHAsMedicine / drugsFragranceNutsLatexSunscreensIodineAnimalsPlants / FlowersOther
Do you have any difficulty laying on your front, side or back:

YesNo
I am, or there’s a chance I could be, pregnant:

YesNo
How many weeks?
I’m going through menopause or HRT:

YesNo
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?

YesNoYes, 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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