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48 Exmouth Market

London EC1R 4QE

United Kingdom

Root Hair and Beauty

+44 7557 535385

info.ellanazar@gmail.com

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Questionnaire and Consent Form

Before your first treatment, please submit this Questionnaire and Consent Form

Full Name

Email Address

Phone Number

Date of Birth

Please tick if you suffer or have ever suffered from any of the following conditions

Heart conditions/angina

Blood pressure problems

Epilepsy/seizures

Haemophilia/blood clotting disorders

Blood borne virus e.g. Hepatitis B/C or HIV

Skin complaints, e.g. psoriasis, eczema

Diabetes

Allergic response e.g. anaesthetics, jewellery

Please tick if any of the following statements apply.

I regularly take blood thinning medicine e.g. aspirine

I take regular prescribed medicine

I take any regular supplements or herbs

I have recently had surgery, dental care, tattoos or piercings

I could be pregnant

If you answered yes to any question, please elaborate

Please type your full name here to sign the consent

Today's Date

I declare that the information I have provided on medical history is correct to the best of my knowledge and hereby give consent for acupuncture to be carried out by Acupuncture by Ella Nazar Limited. I confirm that I have been provided with written information on the potential complications associated with the procedure, aftercare advice and the privacy notice location, all contained in the “Information Sheet” on the “Clinic Info” page of the website.

Thank you for submitting!

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