Step 1 of 4
Your details
Please complete before your appointment. All information is kept strictly confidential.
First name *Required
Last name *Required
Date of birth *Required
Phone number *Required
Email address *Please enter a valid email
Emergency contact name & phone *Required
Service category
Which service have you booked? *
        
      
Please select a service

      
      
    
Step 2 of 4
Treatment questions
These questions are specific to your chosen treatment.
These questions ensure advanced treatments are safe for your skin.
Have you used Retinol, AHAs/BHAs (e.g. Glycolic Acid), or Vitamin C in the last 7 days?Yes
No
Have you had Botox in the last 2 weeks or Dermal Fillers / Threads in the last 4 weeks?Yes
No
Do you have any metal implants, pins, a pacemaker, or a history of epilepsy?Yes
No
Have you used a sunbed or had significant sun exposure in the last 2 weeks?Yes
No
Are you currently taking Roaccutane or any photosensitising medication?Yes
No
Skin typeDry
Oily
Combination
Sensitive
Acne-prone
Normal
Main goal for today's treatmentHydration
Anti-ageing
Brightening / glow
Congestion / deep cleanse
Relaxation
Do you have any allergies to nuts, shellfish, latex, or specific essential oils?Yes
No

          
        
Are you currently wearing contact lenses?Yes
No
Please read each question carefully. These are clinical safety checks required before microneedling.
Do you have a history of Keloid scarring or slow wound healing?Yes
No
Do you suffer from cold sores (Herpes Simplex)?Note: Microneedling can trigger an outbreak. Antiviral medication may be recommended beforehand.
Yes
No
Are you taking any blood-thinning medication (e.g. Aspirin, Warfarin)?Yes
No
Have you used Retinol or prescribed skin treatments in the last 7 days?Yes
No
Preferred pressureLight
Medium
Firm
Deep Tissue
Focus areas — tick all that applyNeck
Shoulders
Lower Back
Hips
Feet
Full Body
Do you have a history of DVT (blood clots), varicose veins, or undiagnosed lumps / swelling?Yes
No

          
        
Cupping consent — if your treatment includes cupping, do you understand that it may leave temporary circular marks on the skin for 3–7 days?Yes, I understand
Not applicable
Your comfort, safety, and wellbeing are Rosemarie's priority. Please answer as fully as possible.
Are you currently:Pregnant
Postnatal
Body massage is only suitable from 13 weeks. Please confirm your stage below.
How many weeks pregnant are you? *Please enter how many weeks pregnant you are
Has your midwife or GP classified your pregnancy as high-risk?Yes
No
Are you experiencing any of the following? (select all that apply)These are red flags for Preeclampsia. If yes, please consult your GP before booking.
Sudden swelling / pitting oedema
Severe headaches
Vision changes
None of the above
Please wait at least 6 weeks after vaginal birth, or 12 weeks after C-section before receiving massage.
How many weeks postpartum are you? *Please enter how many weeks postpartum you are
Type of deliveryVaginal
Assisted (forceps / ventouse)
C-section
Main areas of discomfort (select all that apply)Lower back
Hips / pelvis
Neck / shoulders
Legs / swelling
General relaxation

      
      
    
Step 3 of 4
Safety & health baseline
These questions apply to every treatment and ensure your session is safe.
Do you currently have a fever, a contagious skin condition, or have you been unwell in the last 24 hours?Yes
No
Please consider rescheduling your appointment. Contact Rosemarie on 07754 925647.
Are you currently taking any medications?Yes
No

        
      
Do you have any allergies to skincare products, oils, latex, or nuts?Yes
No

        
      

      Anything else Rosemarie should know before your appointment?
      
    

      
      
    
Step 4 of 4
Consent & declaration
Please read and confirm each statement before submitting.

      
      I understand that massage and facial treatments are not a substitute for medical examination, and I have answered all questions honestly and to the best of my knowledge.
    

      
      I understand this is a strictly professional therapeutic service. Any inappropriate behaviour will result in immediate termination of the session with full payment due.
    

      
      I consent to Rosemarie securely retaining this information for the purposes of providing my treatments. This information will not be shared with third parties.
    

      
      I understand it is my responsibility to inform Rosemarie of any changes to my health before future appointments.
    
Please tick all four statements to continue
Full name as digital signature *Please enter your full name

      Date
      
    

      
      
    

      Something went wrong — please try again. If the problem continues, contact Rosemarie directly on 07754 925647.
    

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Thank youYour consultation form has been received.
Rosemarie will review your details before your appointment.

See you soon.