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Date of Birth
Day
Month
Year
Treatment you're having
Reflexology
Lymphatic Drainage
Dermaluxe Red Light Therapy
Date of Treatment
Day
Month
Year
Time
HoursMinutes
Are You Pregnant?
Yes
No
Medical History

Therapy Information

Have you had reflexology before?
Yes
No

Please tell me your goals from this treatment below. Check all that apply.

Have you had Manual Lymphatic Drainage before?
Yes
No

Please tell me your goals from this treatment below. Check all that apply.

Have you used LED Light Therapy Before?
Yes
No
Do you have any light sensitive conditions? Eg. Lupus or Photosensitivity.
Yes
No
Are you using medications that cause photosensitivity? (Eg retinoids or antibiotics)
Yes
No

Do you have any areas of skin concern/areas of focus? Please tick below.

Contraindication check. Treatments may not be suitable in the following cases. Please tick if any apply:

Client Declaration

I confirm that the information provided above is true and complete. I understand that the therapies are complementary treatments and not a substitute for medical diagnosis or care.


I consent to receive the selected treatments and understand the possible effects and aftercare advice that will be provided.


Date of signature
Day
Month
Year
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