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NATUROPATH MEDICAL LTD

Naturopath Medical Ltd.
240A High Street
Bromley
BR1 1PQ

www.naturopathmedltd.com
moc.dtldemhtaporutanobfsctd-58da2e@ofnI
Mobile/ WhatsApp: 0773 791 5344

Thank you for cooking your treatment with us at Naturopath Medical Ltd. In order to receive the maximum benefit from your treatment or programme please complete this questionnaire and return by email or bring it with you.

Client Information

Firstname

Surname

Date of Birth

Age

Sex

Mob/Tel:

Emergency Contact Name

Emergency Contact Number

Medical History

If you checked any, please provide details:

Allergies & Sensitivities

Do you have any allergies?

Yes No

If yes, list all known allergies (cosmetic, food, medication, latex, etc.):

Do you have sensitive skin?

Yes No

Are you allergic or sensitive to fragrances or essential oils?

Yes No

Medications & Topical Products

Are you currently taking any prescription medications?

If yes, please list:

Other

If yes, when was your last use?

Skin History

Other

How often do you receive professional facials?

First time Occasionally Regularly (every ___ weeks/months)

If yes, when was your last treatment?

Home Care Routine

What skincare products do you currently use? (Cleanser, toner, serum, moisturizer, SPF, etc.)

Do you use sunscreen daily?

Yes No

Do you exfoliate your skin?

Yes No

How often?

Lifestyle Factors

How many glasses of water do you drink per day?

Do you smoke or vape?

Yes No

How many hours of sleep do you get nightly?

Do you wear makeup daily?

Yes No

How would you describe your stress level?

Low Moderate High

Treatment Goals

Other

Consent & Acknowledgment

Please tick the following:

*I understand that facial treatments are intended to improve the appearance and health of the skin and that individual results vary. I have disclosed all relevant health information and will inform my aesthetician of any changes in my condition. * I understand that any package of Colonic Hydrotherapy treatments I purchase is non-refundable and non-transferable * I agree to adhere to the scheduled appointment times. If I need to cancel or reschedule, I will provide at least 24 hours’ notice; otherwise, or if I fail to attend, I will be charged the full session fee. * By signing this form I accept the terms and Condition of ’Naturopath Medical Ltd.’ Printed on the Below

Naturopath Medical Ltd. Terms & Conditions
1. All treatments, courses, and packages must be paid in full either at the time of booking or at the conclusion of your first appointment.
2. To reschedule or cancel an appointment, you must provide at least 24 hours’ notice.
3. Cancellations made less than 24 hours before your appointment—or missed appointments—will result in forfeiture of that session (if part of a course or package) or the full session fee being charged.
4. If you arrive late, only the remaining appointment time will be provided. Arrivals more than 20 minutes after the scheduled start time will result in cancellation of the appointment without refund.
I confirm that I have read and agree to the above terms.*
Please sign and date this Questionnaire

Signature

Date

Please respect others time and if you are unable to keep your appointment, for any reason, please give us as much notice as possible. Thank you