Consultation Form • Maddie Young & Beautiful

Name

Mobile number

Date of birth (dd/mm/yyyy)

Address

Health information
The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge

Back/ Neck problems

Circulatory disorder

Fibromyalgia

Diabetes

Headaches/ Migraines

Heart Condition

Recent accident/ Injury / Surgery

Open wounds / sores

High/ Low Blood Pressure

Post Chemotherapy

Pregnancy/ Breastfeeding

Eczema/ Psoriasis

Bacterial Infections(onychia, paronychia)

Nail Fungal Infections(athlete foot, ringworm)

Viral Infections(warts, verruca)

Contagious skin/ nail condition

Joint Disorder/ Arthritis

Dry/ Watery Eye Syndrome

Do you use eye products (drops)?

Any eye problem in the past 4 weeks?

Do you wear contact lenses? – must be removed before eye treatments

Have you any serious medical conditions i.e. Cancer? If yes, please give brief details:

Are you on any long-term medication? If yes, please give brief details:

Have you tested positive for Covid-19? If yes, please give brief details:

Have you had a Covd-19 vaccine? If yes, please give brief details:

Are you allergic to any of the ingredients in the products(as per list below)? If you are, then unfortunately you will not be able to have the UK Callus Peel treatment. INGREDIENTS OF UK CALLUS REMOVER: Aqua; Lactic Acid; Glycerin; Avena Sativa (Oat) Kernel Flour; Mannitol; Bromelain; Papain; lcoholDenat; Passiflora Edulis Fruit Extract; Ananas Sativus Extract; Vitis Vinifera Extract; Amorphophallus Konjac Root Extract; Phenoxyethanol; Ethylhexylglycerin. INGREDIENTS OF UK AFTERCARE CREAM: Aqua; Raphanus Sativus Seed Oil; Emulsifying Wax NF; Trimethylolpropane Tricaprylate/ Tricaprate ;Butyrospermum Parkii; Glycerin; Phenoxyethanol; Ceteareth 20; Eucalyptus citriodora (Eucalyptus Lemon ) Leaf Oil; Sodium Acrylate / Sodium Acryloyldimethyl Taurate Copolymer; Cetearyl Alcohol ;Ceteth-24; Ethylhexylglycerin Dimethicone; Glyceryl Stearate; PEG-100 Stearate; Isohexadecane;Phospholipids; Steareth-2 Polysorbate 80; Limonene; Citronellol; Linalool.

If you are PREGNANT you will be able to have this treatment as the Callus Remover consists of over 99% natural ingredients but you will not be able to use the Aftercare Cream as this contains a small element of Essential Oils and medical opinion is that these should be avoided in the first trimester.

Other known allergies or health problems, medication (please state)

Skin Care Routine/ What products do you use and how often? Do you ever have reactions to products on your face?

Please advise your skin Type:

Previous negative reaction, allergies to lash/brow tint, hair colour, lash extensions, henna tattoos, nail extensions, adhesives, sticky plasters, to oils, lotions, or ointments?

Do you have any difficulty lying on your front, back, or side?

Do you experience stress in your work, family, or other aspect of your life? If yes, how do you think it has affected your health?

Any additional information?

Agreement Information(required)

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware oft one

I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

I understand that I am responsible for notifying the therapist if any of the above information should change be incorrect or if there is anything preventing me having the agreed treatment

I understand that after I’ve been Patch Tested if no irritation rash swelling or redness occurs during this time the chance of a reaction during treatment is very much less but is never certain and a reaction can still happen after the treat.

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