Booking FormFirst NameLast NameDate of BirthEmailPhone Number*AddressAddress Line 1Address Line 2CityCountyZip Code*Emergency Contact DetailsNameNumberRelationService- Select -CuppingMassageCosmetic Teeth WhiteningIV InfusionVitaminsPRP TherapyAre you currently receiving doctor/hospital treatment? Yes NoAre you currently taking any prescribed medicine (tablets, ointments, injection, contraceptive, hrt or warfarin)? Yes NoAre you currently carrying a medical warning card? Yes NoDo you have any allergies to medications (such as penicillin, latex/rubber, or certain foods)? Yes NoDo you experience asthma, eczema, or hay fever? Yes NoDo you experience fainting spells, blackouts, or seizures? Yes NoDo you have a heart condition, angina, high blood pressure, or a history of rheumatic fever? Yes NoDo you have diabetes? Yes NoDo you experience excessive bleeding? Yes NoDo you have any infectious diseases, such as hepatitis A, B, or C, or HIV? Yes NoDo you currently have or have you ever had liver or kidney disease? Yes NoHave you ever had a blood transfusion? Yes NoHave you ever tried cupping therapy before? Yes NoIf any of the questions are answered with "yes," please provide details of your alignment and the conditions you want treated!Are you pregnant or is there any possibility that you are pregnant? Yes NoAre you breastfeeding? Yes NoDo you suffer from any illnesses e.g. diabetes, angina, epilepsy, hepatitis, auto immune disease? If Yes, please specify. Yes NoDetails PleaseDo you suffer from AIDS or viral hepatitis? If yes, please specify. Yes NoDetails PleaseDo you have, or have you had, any form of skin cancer? If yes, please specify Yes NoDetails PleaseAre you allergic to topical (applied to skin) anesthetics? Yes NoDo you suffer from any known allergies? If Yes, please specify Yes NoDetails PleaseDo you have a history of anaphylactic shock (severe allergic reactions)? Yes NoDo you suffer from keloid or hypertrophic scars? Yes NoHave you been diagnosed with any skin conditions? If yes, please specify Yes NoDetails PleaseAre you taking / receiving steroids, chemotherapy or radiotherapy? If yes, please specify Yes NoDetails PleaseHave you taken oral retinoids (Roaccutane) in the past 6 months? Yes NoHave you taken Aspirin, Warfarin, other anti-coagulant treatments or any other medication or dietary supplements that can affect bleeding time within the last 10 days? Yes NoAre you taking any other medication, including the contraceptive pill? If Yes, please specify Yes NoDetails PleaseHave you used any topical retinoid’s / Vitamin A products in the last 3 days? If yes, please specify Yes NoDetails PleaseHave you used any exfoliants, alpha hydroxy (AHAs) or beta hydroxy (BHAs) acids, hydroquinone, benzoyl peroxide products within the last 3 days? If yes, please specify Yes NoDetails PleaseDo you have a history of herpes simplex (cold sores) or other skin infections? Yes NoHave you undergone a laser resurfacing laser hair removal or dermabrasion in the last 7 days? Yes NoHave you had a skin peel in the last 6 weeks? If yes, please specify Yes NoDetails PleaseHave you been exposed to excessive sun, electrolysis, depilatory creams, or waxing in the last 5-7 days? If yes, please specify Yes NoDetails PleaseHave you previously received any aesthetic treatments (eg Botox dermal fillers, facial fat transfer etc.)? If yes, please specify which treatment, and when your last treatment was Yes NoDetails PleaseHave you previously experienced any reactions from aesthetic treatments (e.g Botox dermal fillers, peels, laser, dermabrasion, facial fat transfer etc.)? If yes, please specify Yes NoDetails PleaseHave you ever had treatment of permanent filler injections? If yes, please specify Yes NoDetails PleaseDo you have any tattoos or semi-permanent makeup in the area of treatment? If yes, please specify Yes NoDetails PleaseDo you smoke? If yes, how many/day? Yes NoDetails PleaseHow would you describe your skin? (please circle) Dry, oily, acne, acne prone, combination, pigmented Dry Oily Acne Prone Combination PigmentedWhat skincare products are you currently using? Retinoids Brands Moisturisers MakeupWhat are your skin concerns? Acne Acne scarring Dryness Dull/Grey Hyperpigmentation Fine Lines & Wrinkles Oil Control Rosacea/Redness Scarring Sun Damage Thread VeinsWhat area of the skin do you want to treat? Face Body Hands ScalpWhat are you hoping to achieve from this treatment?Consent - PRP TherapyI understand this treatment is an elective medical-cosmetic treatment and hereby acknowledge the following:I confirm I do not suffer from oncological, autoimmune and liver diseases Yes NoI have not been treated with anticoagulants (blood thinners) and have not taken Aspirin in the last 10 days. Yes NoI confirm that to the best of my knowledge the health history that I have supplied is correct and that there is no other medical information I need to disclose Yes NoI further understand that withholding any medical information may be detrimental to my health and safety during the treatment in which I agree to undertake Yes NoI understand that if there is any change in my medical history, it is my responsibility to advise the practitioner before further treatments are carried out Yes NoI have been informed in detail and understand possible risks, conditions, reactions, side effects associated with the treatment and I understand that the development of any reactions/side effect must be reported to the practitioner as soon as possible Yes NoI understand I may require a series of treatments to achieve the maximum cosmetic result. Yes NoI certify that I will make available where possible any follow-up visits as my practitioner advises if required - approximately 2-6 weeks. Yes NoThe effects of treatment will vary with some patients than with others and I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no written, implied, or verbal guarantee that the anticipated results will be achieved Yes NoI have understood and agree to follow above post treatment advice given in the form of a leaflet in the knowledge that deviation can cause a disappointing result and, in some instances, can pre-dispose me to side effects and reactions to treatments Yes NoThe treatment has been explained to me by the practitioner and I am aware that my own blood is used to carry out the procedure and I confirm that I agree to the PRP procedure and I have had the opportunity to ask questions and that these have been answered to my satisfaction and I confirm that I have been allowed sufficient time to make a carefully considered decision. Yes NoI understand that pre and post-treatment photographs will be taken and that these will be used for assessment reasons. I can confirm these images are taken with my knowledge and I consent to them being placed in my file. Yes NoI consent to photographs being used for educational, training, teaching, and lectures. Yes NoI consent to photographs being used for: Website Facebook Instagram TwitterPlease ensure you understand the potential complications and personal requirements of the procedure indicated below and please acknowledge or answer the points and questions:Do you have a history of anaphylactic shock (severe allergic reactions)? Yes NoDo you suffer from any known allergies? If yes, please specify: Yes NoDo you have, or suffer from liver or kidney disease? Yes NoAre you undergoing treatment for cancer, or had cancer within the last 5 years? Yes NoDo you suffer from, or have you ever suffered from Deep Vein Thrombosis (DVT) Yes NoAre you taking Aspirin, Warfarin, other anti-coagulant treatments or any other medication or dietary supplements such as Omega-3 that can affect platelet function and bleeding time? Yes NoAre you taking/receiving steroids, chemotherapy or radiotherapy? Yes NoAre you taking any other medication? If Yes, please specify: Yes NoDetails PleaseDo you suffer from any illness e.g. diabetes, angina, epilepsy, hepatitis, auto immune disease? Yes NoDo you suffer from keloid or hypertrophic scars? Yes NoDo you have a history of herpes simples (cold sores) or other skin infections? Yes No Have you suffered from or do you have cardiac disease? Yes NoAre you pregnant or is there any possibility that you are pregnant? Yes NoAre you breastfeeding? Yes NoHave you ever suffered from oedema? Yes NoHave you drank alcohol or taken recreational drugs in the last 48hours? Yes NoI am voluntarily consenting to having I.V. Therapy. _____I understand that participating in the intravenous (I.V.) hydration and vitamin administration services carries risks. _____I understand that failing to inform the staff about my medical issues and/or drug use can lead to serious complications. _____I understand that I am undertaking this treatment knowing the full facts, side effects, treatment outcomes and complications and I will not hold the clinic responsible should any issues mentioned above occur. _____I acknowledge that I am responsible for any medical care I may have that is directly or indirectly related to the services provided .If I seek medical treatment for any side effect or reaction, it will be at my own expense. _____I understand that the clinic or therapist bears no responsibility for and will not screen for, diagnose, monitor, or provide any care for such conditions. I acknowledge that the clinic relies upon information provided by me in assessing my ability to participate in the services provided. _____ I understand that: The procedure involves inserting a needle into a vein and injecting the prescribed solution. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes. Risks of intravenous therapy include but not limited to: Occasionally to commonly: Discomfort, bruising and pain at the site of injection. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. Extremely Rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death. Benefits of intravenous therapy include: Injectables are not affected by stomach, or intestinal absorption problems. Total amount of infusion is available to the tissues. Nutrients are forced into cells by means of a high concentration gradient. Higher doses of nutrients can be given than possible by mouth without intestinal irritation. ______I acknowledge that I have been given the opportunity to discuss the nature and purpose of the treatment and the risks, complications, and consequences associated with the procedures. ______I am aware that it is impossible to foresee or predict all possible risks, complications, and consequences, and I do not expect that staff can anticipate or explain all associated risks. I waive any and all claims related to the services provided and agree to hold the clinic and practitioner harmless regarding any complications or consequences I experience during or following the service. _____Under GDPR rule I understand that I have full access to all data held on me. This data will be held by the clinic for no longer than 6 years for insurance purposes, after which, digital information will be deleted permanently, and paper documents will be destroyed. All information on myself is kept on password encrypted hard drives or locked in filing cabinets to which only selective staff members have access. None of my personal data will be sold or used for anything other than to provide the services of this clinic. Yes, I agree to the above consent I confirm that to the best of my knowledge that the information that I have supplied is correct and that there is no other medical information I need to disclose. I understand that treatments and products is not an exact science and therefore that no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement, not perfection, and that there is no guarantee that the anticipated results will be achieved. I understand that this teeth whitening treatment uses a non-peroxide gel (typically sodium bicarbonate or botanical based) activated by an LED light. This process is designed to remove surface stains and brighten the enamel without the use of harsh chemicals or bleach. Expected Results Natural Limits: I understand that results vary based on my natural tooth shade, diet (coffee, tea, wine), and smoking habits. Maintenance: Non-peroxide whitening is a cosmetic enhancement and may require touch-ups to maintain the desired shade. Artificial Dental Work: I understand that this treatment will not whiten crowns, veneers, fillings, or dentures. It will only remove surface stains from natural teeth. Potential Risks & Sensitivities While non-peroxide treatments are designed to be gentle, I acknowledge the following possibilities: * Minor Sensitivity: Some clients may experience mild tooth or gum sensitivity during or after the session, which usually subsides within 24 hours. * Blanching: Temporary whitening of the gum line may occur if the gel touches the soft tissue; this is harmless and disappears quickly. * Spotting: White spots (decalcification) already present on the teeth may appear more prominent immediately after treatment but typically blend back in within a few hours.Client Attestation I do not have any open sores, bleeding gums, or advanced periodontal disease. I am not currently pregnant or breastfeeding (as a standard safety precaution). I am 18 years of age or older (or have parental/guardian consent).Aftercare Commitment For the next 24 to 48 hours, I agree to avoid "staining" substances such as red wine, coffee, dark sodas, turmeric, and tobacco to allow the teeth to rehydrate and lock in the results.Media & Photo Release I hereby grant permission to Healing Hub to take photographs of my teeth/smile before and after the treatment. I understand these photos may be used for marketing, social media, and educational purposes. My identity will remain anonymous unless I specifically authorize otherwise. I understand that I will not receive any compensation for the use of these images. I AGREE to the photo release. I DECLINE the photo release (I only want photos for my private record).Refund & Satisfaction Policy Variable Results: I understand results can vary because teeth whitening results depend on individual enamel porosity and lifestyle habits, Healing Hub cannot guarantee a specific number of shades lightened No Refund Policy: I understand that I am paying for the service, time, and materials used. Therefore, no refunds will be issued after the treatment has been performed, regardless of the level of whitening achieved.Acknowledgment & Consent I have read the above information and confirm that I am a suitable candidate for this cosmetic procedure. I release the technician from any liability associated with the results of this elective treatment.Vitamin Therapy Informed Consent Form Treatment Description: I hereby authorize Healing Hub to perform the administration of vitamins, minerals, and/or antioxidants. I understand that these nutrients may be administered via: Intravenous (IV) Infusion Intramuscular (IM) Injection Oral Supplementation Purpose of Treatment: To support nutritional status, hydration, energy levels, and general wellness. Risks and Side Effects: While vitamin therapy is generally considered safe, I acknowledge that there are inherent risks, which may include but are not limited to: General: Nausea, dizziness, headache, or a "flushed" sensation. Injection Site: Redness, swelling, bruising, or localized pain at the needle site. Serious (Rare): Allergic reactions, anaphylaxis, vein inflammation (phlebitis), or infection. Financial Responsibility I understand that this procedure is elective and is typically not covered by health insurance. I agree to be responsible for the full payment of the services rendered. I have read this form entirely, and I have had the opportunity to ask questions. I voluntarily consent to the treatment.
