Diamond Face & Body Treatment Consultation Form
All information received on this form will be treated as strictly confidential. Please fill out the form completely and accurately. This information is essential in helping us develop a program that will not only keep you safe but will address your needs and goals as effectively as possible.
Name: DOB:____/____/____ Age:______
Address: ______
Phone: (H) (M) (W)
Email Address: ______
Occupation:
Emergency Contact: Relationship:Phone number:
Medical History: (Please tick any of the following that currently apply to you or have applied to you in the past)
□ Cancer
□ Headaches
□ Chronic pain
□ Diabetes
□ Epilepsy
□ Heart condition
□ High/low blood pressure
□ Allergies
□ □ Varicose veins
□ History of fainting
□ Neck or spine injuries
□ Menstruating
□ Currently under doctor care
□ Pregnancy
□ Kidney problems
□ Liver problems
□ Recent operations
□ Hormone imbalances
□ Hypertension
□ Arthritis
□ Asthma
□ Athletes foot
□ Skin conditions
□ Broken bones
□ The usage of herbal or
natural remedies
Are you current seeking medical treatment from any of the following: Doctor, Naturopath, Chiropractor, Surgeon, Physiotherapist, Massage therapist? If yes please specify.
Are you current taking any medications? If yes please specify.
______
Are you currently taking Warfarin or Aspirin? YES/NO (Please circle)
Do you smoke? If yes how many per day? How many years have you smoked?
Face
How sensitive is your skin?______
Do you have or have you ever had acne?______
What allergies do you have? (Please specify)_
Do you wear contact lenses?______
Have you had or have you ever had any of the following: Keloid scarring, Hepatitis, Dermatitis, Acne Scarring, HIV, Eczema, Skin Cancer, Herpes simplex, other?
Have you ever had any of the following treatments: Laser peel, Glycolic peel, TCA or Jessner Peel, Botox fillers or Injectables?
Do you use or have you ever used: Retin A, Hydroquinone, Roacutane or other?
Body
Do you have any of the following: Epilepsy, a history of seizures, a pacemaker, melanoma, metal pins or plates, diabetes?
______
Are you Pregnant or intending to fall Pregnant?
Have you had Surgery? Please specify below.
______
Please note: Bruising may occur due to the Biomesosculpture treatment but will subside.
Client declaration
I have answered all the questions provided in this form to the best of my knowledge and I am not aware of anything that would further prevent me from having treatments at this clinic. Please note that if you are under current doctor supervision you will need to provide a Doctors Letter of Approval before your treatment can commence.
Client’s signature: Date:
Therapist’s signature: Date: