Contact — Copper Tree Clinic

Contact Me

Please submit this online consultation form prior to attending your first treatment. Please note that all details that you submit on this form are kept strictly confidential. All medical information is required to determine and assess suitability of treatment and will be discussed further during consultation.

Email

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Address

Which service are you enquiring about?

Hair removal (electrolysis)

Blemish removal

Skincare

Are you under medical care? If yes please give details.

Are you taking any medication? Do you have any medical conditions? If yes please give details.

Have you ever had a positive COVID test or the COVID vaccine? (This is asked due to changes that can occur to your skin after a positive test or a vaccine)

Please give details of any skincare routine.

How did you hear about Copper Tree Clinic??

Signature (please type your name)

Please note, by filling in and sending this form to copper tree clinic you are confirming the above information is correct and giving permission for a patch test be given, and before and after photographs to be taken of the treatment area, with each treatment.

Today's date

MM

DD

YYYY

* Please note, a consultation (whether in clinic or via phone call) will be required and further information may be needed prior to treatment.

Contact Me

Copper Tree Clinic, Exmouth