Ears piercing (if under 18 need Parent/Guardian permission form as well)
Please fill out the following health declaration form in order to book a treatment with me. Submissions has to be done prior your booking. Thank you for taking your time to do that. I will check and get in touch, if there are any concerns. Looking forward to pampering you soon.
I agree to inform immediately, if my body temperature is getting higher than 37°C, develop cough or loose my sense of taste and smell in the last 24hrs prior the treatment.
Heart Condition
Yes
No
If YES, elaborate more
High or low blood pressure
Yes
No
If YES, elaborate more
Diabetes
Yes
No
If YES, elaborate more
Cancer
Yes
No
If YES, elaborate more
Bruises
Yes
No
If YES, elaborate more
Loss of skin sensation
Yes
No
If YES, elaborate more
HIV
Yes
No
If YES, elaborate more
Scar Tissue or Keloids (Dr written permission required)
Yes
No
Epilepsy (has to be accompanied with someone + Dr written permission need it)
Yes
No
Medical Odema
Yes
No
If YES, elaborate more
Recent scars or surgeries (under 6 months
Yes
No
If YES, elaborate more
Skin disorders
Yes
No
If YES, elaborate more
Medications
Yes
No
If YES, elaborate more
Allergies
Yes
No
If YES, elaborate more
Hepatitis
Yes
No
If YES, elaborate more
Dysfunctions of the Nervous System
Yes
No
If YES, elaborate more
HIV
Yes
No
If YES, elaborate more
Warts or Moles
Yes
No
If YES, elaborate more
Cysts or undiagnosed Lumps or Bumps
Yes
No
If YES, elaborate more
First Name
Last Name
Email
Phone Number
Address
Please leave instructions for parking. I am caring heavy equipment, so free immediate parking to the property is required.
Please upload a doctors notes, if you have medical condition and require adapting on your treatments
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Date
Your Signature
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