BEFORE YOUR VISIT

A little about you.

Complete your consultation online for Bethany to review before your treatment. You can also discuss these questions at your appointment.

Your full namePhone numberTreatment you are planningDate of birth (optional)Emergency contact name, relationship and number (optional)

Your wellbeing

Please share only what is relevant. Write “None” if it does not apply, or “Discuss privately” if you prefer to talk to Bethany.

How is your general health today?Are you taking any medication?Are you undergoing any surgery or other treatment?Have you had cancer within the past six months?Do you have any allergies?Any skin conditions, such as eczema, psoriasis, dermatitis or acne?Any other conditions Bethany should know about?Anything requiring special care?What would you like from your treatment?

Other conditions may include pregnancy, heart conditions, epilepsy, thrombosis, metal implants, loss of sensation, eye infections, unexplained lumps or swelling. Special care may include diabetes, asthma, blood pressure, circulation, bruising, recent injury or surgery, Botox/fillers or sensitive skin. Bethany will discuss suitability with you; submitting this form does not confirm that a treatment is suitable.

Stress level (optional, 1 = low, 10 = high)

Your privacy & agreement

Your answers are stored in the salon’s protected database and are accessible to authorised salon administrators. They are used to prepare your consultation, not for marketing or AI training. Email alerts, when enabled, contain a link to the private admin area rather than your health answers.

You can remove a submitted form and withdraw consent using the button above, or contact butterflyandrosetherapy@gmail.com. Forms remain stored until deleted by you or an administrator. Tell Bethany if anything changes before your visit. Deleting a form does not cancel your appointment.

I explicitly consent to Butterfly & Rose Therapy storing and using the health information I provide to prepare my consultation. I understand I can withdraw this consent and discuss my answers in person instead.I confirm that my answers are accurate to the best of my knowledge. I will discuss treatment suitability and consent with Bethany before treatment.Type your name to sign

This saves your consultation to the salon’s private admin area. It does not book an appointment.

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A little about you.

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Your wellbeing

Your privacy & agreement