Lotus Massage Treatment Consent Form

Please complete the following.

First name

Last name

Address

Phone

Email

Date of birth

Day

Month

Year

Emergency contact / mobile number

Do you have any allergies?

Have you been hospitalised in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Are you taking any medications?

No

Yes

If you answered yes to the question above, please supply additional information.

Are you pregnant?

yes

no

Reason for seeking treatment

Facials and Facial Massage Treatments

Have you ever used Accutane, Retinol, Retin-A, hydroxyl Acid

yes

no

Do you use products with Glycolic Acid

yes

no

Have you ever had Botox, Fillers, Restylane, Collagen Injections

yes

no

Do you wear contact lenses

yes

no

How did you hear about Lotus Massage Therapy?

I declare that the info I have provided is accurate and complete. I agree to inform my therapist if any of the above information changes at any time and consent to the treatment. I have read the booking terms and cancellation policy, I agree to the terms and conditions.

Date

Day

Month

Year

Signature

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