Private & Confidential Client Consultation Form  

Client Details  

Client Ref:  

Telephone Number:  

Address:  

Mobile Number:  

Occupation:  

Postcode:  

Date of Birth:  

Email:  

Gender:  

Medical History  

Do you or have you ever suffered from:  

Eye infections □ Undiagnosed lumps □ Skin disorders □ Cuts, abrasions, swellings etc □ Extreme sensitive, fluttery eyes □ History of allergies, severe sensitivity to cosmetics etc □  

Allergies:  

Phobias:  

Do you wear contact lenses?  

Yes/No  

Are you claustrophobic?  

Yes/No  

Have you ever had eye treatments before?  

Yes/No  

If YES, did you experience any problems?  

Additional Comments:  

Patch Test Information  

Date:  

Site of lifting lotion:  

Site of fixing lotion:  

Site of adhesive:  

Date:  

Reaction:  

Positive/Negative  

CLIENT STATEMENT & AGREEMENT  

I acknowledge that all the information on this consultation sheet above my signature is accurate and correct to the best of my knowledge. I accept full and complete responsibility for my own emotional and/or physical well-being both during and after this therapy and/or training session. I agree to inform the therapist of any changes to my circumstances during any subsequent treatments. I realise that any advice given to me to carry out between sessions is important and I agree to make every effort to carry this out. I understand that no claim to cure has been made and realise that treatments should not replace conventional treatments.  

Signed: (Client) Date: