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www.basicsalon.com Please fill in and send back as an attachment to [email protected] If you are having problems viewing this form please contact us as we will send you a copy in a different format. Customer Registration Form This is a confidential form and we give you assurance of your personal details upon the Data protection Act. Your personal information will not be shared with any third parties. We will seek your approval for any necessary use of your information. Will have after registration Voters registration number : We are hereby, committed to provide you with excellent service. Please fill in the blanks or mark the appropriate answer as accurate as you can. If you are unsure of the question, please do not hesitate to ask reception who will be happy to help. Title: Miss/Ms/Mrs/Mr/Dr/ First name: Surname: Occupation: Landline number: Date of birth: Mobile: Email: Please mark an X on your answers: What is your interest with us: Hair Skin Body Nails Would you like to receive via email on our pricelist and inform you on any promotional treatments and offers: Yes No Please note that you can view our pricing and promotional treatment on our website: www.basicsalon.com Please mark an X or fill any of the following that applies to you: Epilepsy Impetigo (bacterial) Spastic conditions Severe varicose veins Infections Recent scar tissue Diabetes Cancer: Skin or others Contagious disease High/low blood pressure Psoriasis Contagious disease Eczema Tinea vesicular (Fungal infection) Thrombosis Malignant melanoma Verruca (viral) Pacemakers/heart problems Severe skin conditions diseases or disorders Undergoing medical treatment Scabies/ Infectious contagious diseases Systemic medical conditions Dysfunction of the nervous system Carrier of HIV,AIDS, Hepatitis Cardio vascular problems ie. Heart disease Undiagnosed lumps, bumps, swellings Others: Above are Contra Indications and if you have any of these, you will require medical approval/ referral before any skin treatments or body electro-treatments. 1 This is the copyright of basicsalon ltd, registration no. 06102738 www.basicsalon.com Allergic reactions to products Migraines: Hyper sensitive skin Under influence of alcohol or drugs Pregnant, months Recent operation, (specify where): Bruising on areas, (specify where): Unexplained bodily pain, (specify where): Pigmentation disorder : Sunburn/ heartburn: Metal pins or plates implant, (Specify where) Recent fractures/sprain, (specify where): High anxiety Dermatitis, (Specify where): Botox, (Specify where): Excessive metal dental work Systemic medical condition: Inflammation on the treated area: Severe menstruation pain: Others: Any of the above can prevent and /or restrict to treatments on those areas. Please inform our practitioner before commencement of any treatment. Is there anything that you think our practitioners needs to know prior to your treatments to avoid any bad reaction which we will not be responsible? Please mark with an X which of these you have done or had a test patch: Yes No Yes Date: Hair tint Did you have a reaction Date: Hair Perm Did you have a reaction Date: Hair lightening Did you have a reaction Date: Hair Straightening Did you have a reaction Date: Eyelash/brow tint Did you have a reaction Date: Eyelash perm Did you have a reaction No Other possible contra-action: It is mandatory that the above testes should be done 24hr prior to relate treatments request. Please note that any reaction on the above may restrict the treatment on you. Once you are registered with us, you will be given your customer number which would be needed every time when you use our services. Some questions may be asked when you visit for verification. Please do update us on any changes to your medical condition. Please read our policy, terms and conditions. Our Salon policy: http://www.basicsalon.com/policies.html Our Terms and conditions: http://www.basicsalon.com/termsandconditions.html Do you agree to our terms and conditions? Please sign: ……………………………………… Yes No Date:…………………………. Thank you for registering with basicsalon – hair & beauty workshop 2 This is the copyright of basicsalon ltd, registration no. 06102738