Client Consultation Form – Red Vein Treatments
College Name:
College Number:
Student Name:
Student Number:
Date:
PERSONAL DETAILS
Age group: Under 20
20–30
Lifestyle: Active
Sedentary
Last visit to the doctor:
GP Address:
No. of children (if applicable):
Date of last period (if applicable):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
30–40
40–50
50–60
60+
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical
permission cannot be obtained clients must give their informed consent in writing prior to treatment
(select if/where appropriate):
Pregnancy
Any dysfunction of the nervous system (e.g.
Cardio vascular conditions (thrombosis, phlebitis,
Muscular sclerosis, Parkinson’s disease, Motor
hypertension, hypotension, heart conditions)
neurone disease)
Haemophilia
Neuralgia
Any condition already being treated by a GP or
Inflamed nerve
another practitioner
Cancer
Medical oedema
Spastic conditions
Nervous/Psychotic conditions
Undiagnosed pain
Epilepsy
When taking prescribed medication
Recent operations
Endocrine disorders
Diabetes
Whiplash and any neck conditions
Asthma
Slipped disc
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or
alcohol
Diarrhoea and vomiting
Hepatitis B
HIV/AIDS
Anti coagulant drugs
Loss of skin sensation
Bells Palsy
Keloid scarring
Skin diseases
Undiagnosed lumps and bumps
Localised swelling
Inflammation
Anaphylaxis
Varicose veins
(select if/where appropriate):
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and 6
months for a small scar)
Sunburn
Abdomen (first few days of menstruation
depending how the client feels)
Haematoma
Recent fractures (minimum 3 months)
Hyper pigmentation
Botox/dermal fillers (1 week following
treatment)
Hormonal implants
Cervical spondylitis
WRITTEN PERMISSION REQUIRED BY:
GP/Specialist
Informed consent
Either of which should be attached to the consultation form
Version 3
Previous Red Vein treatment: No
Yes
(if yes how long ago):
Result of previous treatment (if applicable):
Detail of any skin reaction (if applicable):
Present hair and skin condition(select if/where appropriate):
Normal skin/Good healing
Prone to pigmentation patches
Sensitive/Prone to reaction
Very dry skin
Oily & blocked
Erratic/Slow to heal
Subject to blemishes/Cysts
Scars present
Area on the face to be treated:
Intensity used:
Machine used:
Treatment details to include needle size:
PHOTOS BEFORE, DURING AND AFTER TREATMENT
Client feedback:
Aftercare and Home care advice:
Client signature.......................................................
Student/Therapist signature...................................
Date...........................................................................
RED VEIN FOLLOW-UP SHEET
Area on the face to be treated:
Version 3
Intensity used:
Machine used:
Treatment details to include needle size:
Client feedback:
Aftercare and Home care advice:
Version 3