LPG Form English

LPG Form (English)

First name

Last name

Date of birth

Address

Postal code

City

Phone

How did you hear about us?

Full name

Phone

	YES	NO
Are you pregnant?
Are you breastfeeding?
Do you have a history of malignancy?
Do you currently have an active infection or fever?
Are you taking anticoagulant medication?
Do you have a heart condition?

	YES	NO
Do you have phlebitis?
Do you have a history of thrombosis?
Do you have severe varicose veins?
Are there open wounds, recent scars, or bruises?
Is there a skin condition in the treatment area?
Is there chronic pain in the area?
Do you have implants or a pacemaker?

I declare that the information provided is true and I undertake to inform you of any change.

I consent to receiving informational messages and emails about offers, promotions, and news.

I consent to the taking and publication of photographs or video, if requested, for communication and promotional purposes of Beauty in the City.

I give my consent for my personal data to be retained in the records of Beauty in the City.