Rosewood Beauty Studio

Beauty Consultation

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Personal Details

Tell us a little about yourself.

First Name *

Surname *

Address *

Phone *

Email *

Date of Birth * You can type your date of birth (dd/mm/yyyy) or choose it from the calendar.

Skin information — please tick any that apply:

Sensitive skin

Rosacea

Eczema

Psoriasis

Acne

Products & Treatments

Current products used at home

Previous chemical peels

Yes No

Previous laser treatments

Yes No

Previous Botox

Yes No

Previous dermal fillers

Yes No

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Medical History

Help your therapist provide safe treatment.

Are you pregnant or breastfeeding?

Yes No

Allergies

Other medical conditions

Patch Test

I confirm a patch test has been completed where required, or I accept treatment without one where appropriate.

✓

Treatment Consent

I consent to receive the treatment discussed today and understand I may withdraw consent at any time. *

✓

Data Protection (UK GDPR)

I consent to my personal data being processed for the purposes of my treatment and care records, in accordance with UK GDPR. *

How did you hear about us?

I hereby declare that the details are true and correct to the best of my knowledge and I undertake to inform you of any changes immediately. I have read and acknowledged the Privacy/GDPR policy. Thank you kindly for visiting us today and completing this form. Hope to see you again soon.

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Client Signature *

Please sign below.

Please provide your signature

Date *

Age Restriction

We can only offer treatments to people aged 16 and over.

Additional Information

Secure Form from CliniForm

demo.beauty@live-demo.cliniform.test