Consent Form - Angel Trichology

PRE-TREATMENT CONSENT

This form will be sent directly to your qualified trichologist. Your personal information is kept with the strictest of confidence.

YOUR NAME:

Occupation

Age:

Address:

City:

Phone:

Email:

Emergency contact:

Medical history

Acne

Yes No

Eczema

Yes No

Psoriasis

Yes No

Bruising

Yes No

pigmentation

Yes No

Sunburn

Yes No

Pregnant

Yes No

Panic attacks

Yes No

Anti coagulants

Yes No

Thyroid

Yes No

Diabetes

Yes No

Asthma

Yes No

Hyper sensitive skin

Yes No

HIV Hep blood borne virus

Yes No

cancer/ chemotherapy

Yes No

heart disorder

Yes No

Thrombosis

Yes No

blood pressure

Yes No

Do you have any allergies?

Yes No

do you suffer cold sores ?

Yes No

Existing infections, bacterial, viral or fungal

Yes No

Aftercare advice Post Treatment Advice: Avoid the below for 48 hrs

Swimming
Sunbeds
Exfoliant
Tanning
Exercise
Alcohol

I will follow above aftercare advice

I understand that providing this information a treatment plan will be formulated. I also understand that any inaccurate information may compromise the effectiveness of the treatment, I agree that I have been given the opportunity to ask all questions and addressed any concerns.

I give permission for my images to be shared

Yes No

Client name

Client sign

Get the hair that you deserve

Book your consultation today

Click here

Opening Hours:
Monday – Friday 9am – 5:30pm

Phone: 078173 22235
Email: [email protected]

Address: Main Street, Kilby Wigston, LE18 3TD

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PRE-TREATMENT CONSENT

Medical history