Consent Form

Address: 19 Easter Road, Edinburgh, EH7 5PJ, GB
Telephone: 0131 652 1988

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Client medical history
Do you currently suffer from, or have you ever suffered from any of the following?
Do you have the capacity to make your own informed decisions?*
- Yes
- No
Heart Condition/Angina*
- Yes
- No
Description*
Blood Pressure Problems*
- Yes
- No
Description*
Epilepsy/Seizures*
- Yes
- No
Description*
Haemophilia/Blood Clotting Disorders*
- Yes
- No
Description*
Blood borne Virus, e.g. Hepatitis B/C or HIV*
- Yes
- No
Description*
Skin Complaints, e.g. psoriasis, eczema, dermatitis*
- Yes
- No
Description*
Diabetes*
- Yes
- No
Description*
Allergic Response, e.g. anaesthetics, jewellery*
- Yes
- No
Description*
Are you prone to fainting attacks?*
- Yes
- No
Description*
Do you regularly take any blood-thinning medicines, e.g. aspirin?*
- Yes
- No
Description*
Do you take any regularly prescribed medication?*
- Yes
- No
Description*
Are you, or could you be pregnant?*
- Yes
- No
Description*
Are you breast feeding?*
- Yes
- No
Are you Vegan?*
- Yes
- No

How did you hear about us?
Terms*
I agree that it is my responsibility to read this and follow the aftercare advice given until the treatment area is healed.

I give consent to the operator to retain the details provided on this form for a minimum period of two years from today.
- I agree to the Terms of Service
Almost there!
Hit submit and you will be redirected to digitally sign the consent form

Client medical history