Facial Information Form

First & surname? *

Date of Birth? *

DD/MM/YYYY

First line of your home address & postcode? *

Telephone number? *

Email? *

Confirm Email

Any medication taken? *

If you have answered yes to any of the medical conditions, please give details:

Do you suffer from any skin disorders or scalp infections? *

Any other relevant information

Are you pregnant? *

I declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes to my health or medication. I am happy to receive holistic facial. *

Parental signature if client is under 16 years old

JEANETTE HAYTON M.A.R., LTA Cert.

JEANETTE HAYTON M.A.R., LTA Cert.