Dee’s Beauty Consultation Form

Contact Information

Name:		Mobile No.:
Address:		Email:
Home No.:		Date of Birth:

Do you have or have you suffered from any of the following (please tick all that apply):

Health Questionnaire

MS	Diabetes	Eyelid Surgery
High/Low Blood Pressure	Blurred Vision	Botox Injections
Epilepsy	Asthma	Collagen Injections
Thyroid Disturbances	Bruise/Bleed Easily	Scar Easily
Cancer	Retina A (within 6 months)	Healing Problems
Stroke	Skin Sensitivity	Roaccutune (within 6 months)
Claustrophobia	Sunbed User	Contact Lense Wearer
Other (please specify)

Are you pregnant?	YesNo
Do you smoke?	YesNo
Do you have any allergies?	YesNo
Are you currently seeing your GP for any medical conditions?	YesNo
Have you had any operations in the last 12 months?	YesNo
Are there any concerns that you have at the moment	YesNo

If you have answered YES to any of the above, please give further details

Please list any medications that you have taken or are taking within the last 12 months?

I certify that I have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse effects in which case I accept full liability and responsibility. I accept that any treatment I have is taken at my own risk.

I fully understand the above and consent to the treatment(s) to be carried out which have been fully explained to me.

Signed:		Date:
Print Name:

GDPR

Due to changes regarding the General Data Protection Regulation (GDPR), I am updating my privacy policy.

I would like to take the opportunity to clarify that Dee’s Beauty holds the following data:

• Beauty Consultation Form (medical form)
• Contact Information
• Name
• Address
• Telephone Number
• Email

Your data will not be shared with any third parties. Your data will remain on file whilst you are a client of Dee’s Beauty. Client details will also be kept in line with business accounts for the appropriate period.

Please advise of your preferred method of communication (tick):

TextEmailPhone

To ensure regulatory compliance, written confirmation needs to be obtained from all clients that they are satisfied with Dee’s Beauty holding such information.

Signed:		Date:
Print Name: