CLIENT CONSULTATION FORM - Georgie's Beauty CONSULTATION FORM.pdfCLIENT CONSULTATION FORM CONTACT DETAILS First Name: Surname: Date Of Birth: Gender: Address: County:

Download CLIENT CONSULTATION FORM - Georgie's Beauty   CONSULTATION FORM.pdfCLIENT CONSULTATION FORM CONTACT DETAILS First Name: Surname: Date Of Birth: Gender: Address: County:

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CLIENTCONSULTATIONFORMCONTACTDETAILSFirstName: Surname:DateOfBirth: Gender:Address: County:Postcode:Telephone: Mobile:Email:MEDICALHISTORYDoyousufferfromanyofthefollowing? Allergies ThyroidProblems Headaches High/LowBloodPressure HeartCondition VaricoseVeins Eczema/Psoriasis Cancer IBS/BowelProblems Arthritis/Rheumatism Epilepsy Claustrophobia Asthma/LungProblems BackProblems FungalInfection Diabetes MuscularPain OtherIfyouhavetickedanyoftheabove,pleasegivedetails: Areyoucurrentlyonanymedicationorundermedicalsupervision? Yes NoIfyes,pleasegivedetails:Haveyouhadanysurgeryoroperationsinthelast6months? Yes NoIfyes,pleasegivedetails:Areyoupregnantorbreastfeeding? Yes NoIhavereadandunderstoodthequestionsaskedandconfirmthattheanswersIhavegivenarecorrectandthatIhavenotwithheldanyinformationthatmayberelevanttomytreatments.Signed: Date:

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