JAVANESE BEAUTY CLIENT FORM
The skin care, health and medical information you have provide is used to help your Beauty Therapist to recommend skin care treatments, home care products that are suitable for your skin and conditon. This information will be kept on the up most confidence. Incorrect or withheld information may result in an adverse effect of the treatments.
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Email *
First Name *
Surname *
Address must be the same as shown on your ID
Street Number & Street Name: *
Suburb: *
Postcode: *
State: *
Occupation *
Date of Birth *
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Mobile Phone *
LIST OF ANY OF THE FOLLOWING THAT  YOU TAKE REGULARLY: *
Medications/ Vitamis/ Supplements/ Vitamins/ Diuretics/ Simming Tablet, etc......
Do you regularly suffer from stress? *
Do you wear contact lenses? *
Do you have an eye infection at the moment? *
Do you have sensitive eyes? *
What is your pain treshold? *
HAVE YOU EVER HAD a REACTION TO ANY OF THE FOLLOWING:
Medicine? (YES or NO) - If YES, please specify.... *
Iodine *
Pollen *
Animals? (YES or NO) - If YES, please specify.... *
Food? (YES or NO) - If YES, please specify... *
Nuts *
Hydroxyl Acids *
Latex *
Cosmetics? (YES or NO) - If YES, please specify... *
Sunscreen *
Fragrance *
Essential Oils? (YES or NO) -  If YES, please specify... *
Medical History & Precautions. Have you ever had a serious illness or major surgery? (YES or NO) - If "YES" please specify... And was there any complications, please specify... *
Do you suffer from any of the following conditions? *
Required
Have you had any of the following health problems or skin treatments in the past or present:
Cancer? (YES or NO) - If YES, please specify? *
Diabetes?   *
Epilepsy? *
Heart Problem? *
Hormones Imbalance? *
Immunocompromised? *
Hysterectomy? (YES or NO) - If YES, please specify when? *
Chemical Peels? (YES or NO) - If YES, please specify when? *
Laser Resurfacing? (YES or NO) - If YES, please specify when? *
Roaccutane or Retin-A? (YES or NO) - If YES, please specify when? *
Microdermabration? (YES or NO) - If YES, please specify when? *
Botox? (YES or NO) - If YES, please specify when and which area on your face & body? *
AHA? (YES or NO) - If YES, please specify when? *
Collagen/ Hyalauron injectables? (YES or NO) - If YES, please specify? *
Back problems? *
Metal plates or pin implant (pacemaker, etc)? (YES or NO) - If YES, please specify where is in your body / face? *
Breast augmentation? *
HIV?   *
Hepatitis? *
Are you currently having Covid-19 Coronavirus? *
Required
CLIENT DISCLAIMER: I have carefully read and filled in the details to the best of my knowledge and choose to undergo treatments with your Beauty Therapist and Makeup Artist. *
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A copy of your responses will be emailed to the address you provided.
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