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Infinity Beauty Academy Mandurah

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Student / Model Consultation Record

This form is a vital component of the Infinity Beauty Academy training program. It serves as a foundation for a professional and safe client/model interaction, guiding our students in developing essential consultation skills. For insurance policy purposes, this form must be completed.

Step 1 of 2

50%

Comments

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address

Daytime Phone(Required)

Evening Phone

Date of Birth:(Required)

Gender Pronoun

GP Name

GP Surgery Phone

Surgery Address(Required)

Are you under the care of a medical practitioner?(Required)

Yes

No

Please advise which practitioner and why:

Are you taking any medication / homeopathic remedies?(Required)

Yes

No

Please list the medication / homeopathic remedies:

Do you wear contact lenses?(Required)

Yes

No

Are you pregnant?(Required)

Yes

No

Are you breastfeeding?(Required)

Yes

No

Which trimester?(Required)

1st

2nd

3rd

Do you or have you suffered from any of the following?(Required)

Select each condition that applies to you

Cancer

Heart Problems

Pacemaker

High Blood Pressure

Low Blood Pressure

Asthma

Epilepsy

Diabetes

Liver Ailments

Kidney Ailments

Recent Surgery

Allergies

Skin Diseases / Contagious

Skin Disorders

Varicose Veins

Lack of normal skin sensation

Recent Scar Tissue

Arthritis

Auto Immune Disease

Anxiety

Depression

Thrombosis (DVT)

None of the above

Details of your condition/s:

Is GP Approval Required?(Required)

Yes

No

GP Approval Received?(Required)

Yes

No

Skin Type:(Required)

Oily

Normal

Combination

Dry

Skin Condition:(Required)

Sensitive

Mature

Dehydrated

Do you consent to photos being taken and use for advertising purposes?(Required)

Yes

No

How did you hear about our us?

Google Search

Facebook

Instagram

Other

I heard about you from:

Client Declaration(Required)

I declare that the information I have given is correct. I am aware of no underlying condition that would prevent me from undertaking treatments or may cause any adverse effects to the treatment prescribed. I have been fully informed about contra-indications and I am therefore willing to proceed with treatment. I acknowledge that the therapist providing this treatment is a trainee and I agree to this.

I agree

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0480 316 758

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