CONSULTATION | BLISS & BLUSH SPA

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CONSULTATION FORM

Please fill out the following form.

First name

Last name

Birthday

Month

Day

Year

Address

Email*

DO YOU UNDERSTAND THIS POLICY?

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Yes

Gender

Male

Female

Medical History

ACNE

ARTHRITIS

ASTHMA

BLOOD DISORDER

CANCER

DIABETES

ECZEMA

EPILEPSY

FEVER BLISTERS

HEART CONDITION

HERPES

HEPATITIS

HIGH BLOOD PRESSURE

HIV/AIDS

HYPER PIGMENTATION

HYPO PIGMENTATION

HYSTERECTOMY

IMMUNE DISORDERS

INSOMNIA

KELOID SCARRING

LOW BLOOD PRESSURE

LUPUS

METAL BONES PINS/PLATES

PHLEBITIS BLOOD CLOTS

SEIZURE DISORDER

SKIN DISEASE/LESIONS

SEBORRHEA

THYROID CONDITION

VARICOSE VEINS

WARTS

Initials*

I declare that the info I’ve provided is accurate and complete.

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