CLIENT CONSULTATION FORM
TREATMENT TYPE:
CLIENT NAME
ADDRESS
TELEPHONE
EMAIL
:
:
:
:
PERSONAL DETAILS:
Age Group:
Gender:
Under 20
Female
Male
20-30
30-40
40-50
If female, last date of period:
50-60
60-70
If female, no. of children:
Profession: ______________________________________________________________________________
GP name, address & telephone: _____________________________________________________________
Last visit to the doctor, reason & outcome: ____________________________________________________
CONTRAINDICATIONS REQUIRING MEDICAL REFERRAL:
__________________________________________
Patient History
Yes
No
Have you had any surgeries? If yes, explain: _______________________________
Yes
No
Do you or have you ever had cancer or tumor? _____________________________
Yes
No
Are you diabetic? Type of medication taking: _______________________________
Yes
No
History of kidney failure? : _______________________________________________
Yes
No
History of heart disease? ________________________________________________
Yes
No
History of Seizures/Headaches/Dizziness? For how long? ________________________
Yes
No
History of sickle cell anemia/Blood Disorder? ________________________________
Yes
No
History of asthma? _________________________________________________________
Yes
No
History of Hypertension? ___________________________________________________
Yes
No
History of Liver Disorder? ___________________________________________________
Yes
No
History of recent heart attack? ______________________________________________
BNC Beauty; Beauty Network Connection
Address
Email
Web
Tel
: 25 Hamilton St. Kew East, Vic. 3102
: info.bncbeauty@gmail.com
: www.bncbeauty.weebly.com
: 0412 082 911
Yes
No
Do you have a pace maker? _________________________________________________
Yes
No
Do you have varix or any other vascular diseases? ____________________________
Yes
No
If female, are you pregnant? ________________________________________________
Please list any allergies you have:
_________________________________________________________________________________________
Please list present medications and dosages you use and date of last dose taken (Accutane,
Antibiotics, Aspirin, Antiviral, Iron supplements, Gold therapy, Coumadin, drugs which may cause
photosensitivity including herbal supplements):
_________________________________________________________________________________________
Do you have a history of any autoimmune disease? ___________________________________________
Do you have a history of HSV I or HSV 2 _____________________________________________________
Do you have any metal or silicone implants/injectables/permanent make-up? If so, please list:
_________________________________________________________________________________________
Previous Laser Treatment, Frequency and last use: (specify date/number of
treatments/frequency/tissue response/devise used, if known):
_________________________________________________________________________________________
Other type treatment:
_________________________________________________________________________________________
Have you ever had a cosmetic peel/cosmetic procedure? Please list
_________________________________________________________________________________________
Authorization for Treatment
I, ____________________________, attest that the answers I have provided to questions on this form are
correct to the best of my knowledge. I have read and understand the entire contents of this form and have had
the opportunity to ask questions regarding the information on this form. I agree that the information listed
above has been reviewed and presented with my clear understanding of what this procedure involves All of my
questions have been addressed to my satisfaction. Therefore, I authorize, BNC Beauty (Beauty Network
Connection) to apply a laser/ultrasound/radio frequency treatment on me.
Name:_______________________Date: ____________Signature____________________
BNC Beauty; Beauty Network Connection
Address
Email
Web
Tel
: 25 Hamilton St. Kew East, Vic. 3102
: info.bncbeauty@gmail.com
: www.bncbeauty.weebly.com
: 0412 082 911
FOR STAFF ONLY:
Recommendations: Discussion with provider (tick as you go)
1. _____ Treatment options (testing, number of treatments).
2. _____ Client expectations: (understand need for multiple treatments, after care, possible side
3. _____ Effects: hyperpigmentation, hypopigmentation, purpura, scarring, textural changes,burns,blistering, pain or
….…..discomfort and erythema and length of time to expecthealing if side effects occur., etc).
4. _____ Full treatment schedule process (waiting period in-between treatments, expected results.,)
5. _____ Specifics of area to be treated. Test small area for tissue response BEFORE full treatment.
6. _____ Benefits of treatment
7. _____ Cost of treatment (payment schedule, cost of multiple treatments versus single payment per visit).
8. _____ Importance of post care instructions/procedures.
INTENSITY/FREQUENCY OF TREATMENTS: ___________________________________________________________
_________________________________________________________________________________________________
Photo taken today: ___YES____ NO____ attach the photo
Weight and height measured today: ___YES____ NO____ results of each session WITH DATES:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Measurements taken today: ___YES____ NO____ results of each session WITH DATES:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Fat, muscle and water ratios taken today:___ YES____ NO____ results of each session WITH DATES:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
COMMENTS AND NOTES:
BNC Beauty; Beauty Network Connection
Address
Email
Web
Tel
: 25 Hamilton St. Kew East, Vic. 3102
: info.bncbeauty@gmail.com
: www.bncbeauty.weebly.com
: 0412 082 911