Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Are you 18 or over?*
Date of Birth*
Email Address*
Are you currently on any medication? If yes, please state:*
Have you received body treatments before? If yes, please state:*
Please advise if any of the following apply and provide further details: Heart Disease, Recent Haemorrhage, Active migraine, Dysfunction of the nervous system, Skin disorders, Diseases, cuts or abrasions in the area to be treated. Recent operations or Scar tissue, infections, pregnancy, loss of feeling in skin, high or low blood pressure:*

I can confirm that I understand the treatment and the contraindications. I can confirm that the above statement are true, knowing that the therapist needs the information for correct treatment of my skin.

I understand the therapist can not accept any responsibility for any injury suffered by me due to not giving full and true answers to the above questions. I agree to follow the recommended aftercare where necessary.*
Sign Your Name*