Maderotherapy Personal Data 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 currently under a doctor's supervision?
Are you taking medication?
Have you had surgery recently?
Heart disease / Hypertension / Hypotension / Pacemaker? (Doctor's approval required)
Autoimmune diseases?
Allergies?
Asthma?
Constipation?
Do you drink enough water?
Diabetes?
Hyperthyroidism / Hypothyroidism?
Circulatory problems?
Thrombosis / Varicose veins / Phlebitis?
Dermatological conditions?
Current pregnancy / Breastfeeding?
Have you had any recent injury?
Have you had Botox / Hyaluronic acid (fillers) / Threads?

Is there anything else you would like us to know?

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

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