Lily Bellas

Client Consultation Form

Please complete this consultation form before your appointment. This helps us assess treatment suitability and provide services safely and appropriately.

Before you begin

Please answer honestly and fully. Any medical information you provide helps us make safe treatment decisions.

Client Details

Please complete your basic contact information below.

Client's Name

Phone Number

Email Address

Treatment Booked

Medical History

Please tick any that apply.

Allergies (cosmetics, latex, adhesives, etc.) Sensitive skin Eczema / Psoriasis / Dermatitis Rosacea (redness on face) Diabetes Epilepsy High or Low Blood Pressure Heart conditions Asthma Recent surgery Cancer or undergoing chemotherapy Any skin conditions Eye infections or conjunctivitis

Anything else we should know?

Current Health & Skincare

Please answer all questions below.

Are you currently pregnant or breastfeeding?

Yes No

Are you taking medication?

Yes No

If yes, please specify

Are you using Retinol, Accutane, or strong skincare?

Yes No

Are you taking blood thinning medication?

Yes No

Have you had Botox or fillers in the last 2 weeks?

Yes No

Have you had a patch test in the past 6 months?

Yes No

Do you have contact lenses?

Yes No

Have you had any relevant patch tests?

Yes No

Consent

Please confirm each statement before submitting.

I confirm the information I have provided is accurate. I understand some treatments carry risk of irritation or allergic reaction. I agree to follow aftercare advice given by my therapist. I consent to treatment being carried out.

Do you consent to photos/videos for social media?

Yes No

Signature

For online submissions, please type your full name as your signature.

Signature

Date

Your information will be used for consultation, treatment suitability, and client safety purposes only. By submitting this form, you confirm the information provided is true to the best of your knowledge.

Please check your answers carefully before submitting.

Lily Bellas · Client consultation and treatment consent form