Book an Appointment

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Tick any boxes that relate to you.

Cold sores

Herpes

Diabetes

Glaucoma

High blood pressure

Blood clotting

Accutane / Roaccutane / Isotretinoin - Or in the last 12 months

Oily skin

HIV / AIDS

Pregnant / Breast feeding

Latex allergy

Surgery in the past 3 months

Allergies - Penicillin

Heart problems

Collagen / Facial filler

Alopecia

Hemophilia

Hepatitis A B C

Epilepsy

Under 18 years of age

I understand that when providing the information in this form I consent to the use of this information for provision of services by the therapist. I consent to the uploading of my personal information to a cloud computer network. The information in this form and associated with the treatment will be held in accordance with the NZ Privacy Principles & the Privacy Statement. *

Yes