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First name

Last name

Email

Phone

What is your age group?

15-21

21-30

31-40

41-50

51-60

Over 60

I agree to be contacted by phone or email.

Please tick any of the condtions you have:

Abdominal/ Digestive problems

Allergies

Arthritis

Asthma or lung conditions

Blood clots

Cancer / Tumors

Chronic Fatigue

Chronic pain

Depression

Diabetes

Fatigue

Fibromyalgia

Headaches or migraines

Hearing problems

Heart, circulatory problems

Hernias

High / Low blood pressure

Infectious disease

Lymph node removal

Motor vehicle accident / trauma

Muscle or joint pain

Muscle, bone injuries

Numbness or tingling

Phlebitis

Pregnancy

Rash, athletes foot/tinea

Seizures

Skin disorders

Stroke

Varicose veins

Vision problems/contact lenses

Other

None

Pigmented lesions

Recent cosmetic injectable treatments

Recent IPL or Laser

Post- surgery wound healing

Open skin

Undiagnosed lumps

Other conditions not listed above:

Current medications (including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies):

How much water do you drink per day?

Leisure Activities:

Alcohol Consumption:

Eating Habits:

Are you a smoker? How much per day?

Work Habits (hours/day)

Emotions and mental health at the moment?

Sleeping Habits:

What is your current skincare routine?

What is your goals for your make-up look?

I agree to for the therapist to use Heidi Help - a note transcribing AI.

I agree to the terms & conditions and give consent for my treatment.

I agree for my photos and videos to be used.

I understand the potiential risks and adverse reactions of the makeup treatment.

Signature

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