CLIENT CONSULTATION FORM:
Name & Surname: ________________________________________ DOB: ____________________
Cellphone: _____________________ Email: __________________________________ Therapist: __________________________
PLEASE ANSWER ALL THE QUESTIONS BELOW:
______________________________________________________________________________________________________________________________________ Has the Epilfree result expectations been explained to you?
1
______________________________________________________________________________________________________________________________________ Do you understand the Epilfree expectations?
2
______________________________________________________________________________________________________________________________________ Are you able to do the 6 hours Aftercare Protocol?
3
______________________________________________________________________________________________________________________________________ Do you have a health issue we should know about?
4
______________________________________________________________________________________________________________________________________ Are you on Hormone Replacement Therapy?
5
______________________________________________________________________________________________________________________________________ Are you having Hormonal imbalance?
6
______________________________________________________________________________________________________________________________________ Do you have PCOS (Polycystic Ovarian Syndrome)?
7
______________________________________________________________________________________________________________________________________ Do or did you have botox done?
8
______________________________________________________________________________________________________________________________________ Do you have a physical illness that you feel needs to be discussed?
9
______________________________________________________________________________________________________________________________________ Are you pregnant or breast-feeding?
10
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