Client Consultation Form | Levana Beauty Co

Personal Details

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Allergies & Sensitivities

Do you have any known allergies? *

Yes No

Please describe your allergies

Do you have highly sensitive skin? *

Yes No

Have you had a reaction to a beauty product or treatment before?

Yes No

Please describe the reaction

Medical Conditions

Please tick all that apply. This information is used solely to ensure your treatment is safe.

Any other medical conditions not listed?

Skin Conditions

Any other skin conditions?

Medications & Treatments

Are you currently taking any medications? *

Yes No

Please list your medications

Have you had fillers or botox? *

Yes No

Please give details (area treated & approximate date)

Are you currently using any prescription skin treatments?

Yes No

Please describe (e.g. Roaccutane, retinoids, steroids)

Previous Treatments

Have you had this treatment before?

Yes No

Where and when, and did you have any reactions?

Any other information you'd like us to know?

Declaration

I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform Levana Beauty Co of any changes to my health or circumstances prior to future appointments.

I consent to the information being held securely and used for the purpose of providing safe and appropriate treatments.

Full Name (signature) *

Date *

Thank You