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 taking medication?
Do you suffer from any chronic illness?
Do you have an allergy to any medication?
Are you dealing with any dermatological problems?
Communicable diseases?
Do you have metal implants or a pacemaker?
Are you pregnant?

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.

	YES	NO
Do you smoke?
Do you exercise?
Do you follow a healthy diet?
Do you sleep enough?
Do you drink enough fluids?
Do you consume alcoholic drinks?