Client Model Medical & Treatment Choice Form – Creative Touch

Client Medical & Treatment Request Form

Thank you for showing an interest in becoming a model here at Creative Touch. Please complete the form below all sections will be required in order for us to process the request to be added to the models register.

Treatment consultation, patch testing and treatment consent forms will still be required these will be provided once treatments have been booked.

Name

First

Last

Date Of Birth

Email address

Contact Number

Address

Emergency Contact Name

First

Last

Emergency Contact Number

Doctors Surgery Name & Telephone Number

Do you have any medical problems? (Asthma, diabetes, heart problems etc

Do you have any autoimmune conditions, cancers, blood disorders, neurological conditions, muscle disorders, facial problems or skin conditions? (Bells palsy, epilepsy etc…)

Are you currently under the care of a doctor, clinic, hospital or specialist?

Are you taking any medications? If so, which ones.

Are you allergic to anything? (Medications, latex, pollen etc…)

Are you or could you be pregnant, breastfeeding or undergoing IVF?

Is there any other condition or significant information we need to know about that may affect you during or after this procedure?

Have you ever had an allergic reaction/ irritation or complication from a beauty or aesthetic service?

I consent to being a model for training purposes at Creative Touch. I understand that treatments will be performed by training students under the supervision of a qualified therapist and tutor.

Agree

Do not agree

I consent to being contacted for marketing purposes in relation to up and coming availability for model spaces and special offering at Creative Touch.

Agree

Do not agree

I am happy to be contacted for marketing purposes by:

Text Message

Phone

Post

I understand that it is imperative that I disclose all of the information requested in the Client Profile/Health History/ consultation and consent forms.

Agree

Do not agree

I understand that patch tests may be required and Creative Touch will contact me to arrange this prior to attending to model for a treatment. I understand that if a patch test is not completed service may be refused.

Agree

Do not agree

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications

Agree

Do not agree

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.

Agree

Do not agree

I consent to “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes. These may be used on social media and websites connected with Creative Touch Group Limited. If do not have to consent to this, and it will not affect my treatment in any way.

Agree

Do not agree

Signed

This field should be left blank

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Client Medical & Treatment Request Form

Thank you for showing an interest in becoming a model here at Creative Touch. Please complete the form below all sections will be required in order for us to process the request to be added to the models register.

Treatment consultation, patch testing and treatment consent forms will still be required these will be provided once treatments have been booked.

Company

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