Head2Soul CACI Consultation Form

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Please fill in the following answers. After we will get in contact with to let you know if you are suitable for treatment and what treatment we would recommend to you.

What is your name?

What are your contact details? *

Have you ever had a Caci facial before or any other face-lifting facials?

What are your target areas of concern?

What are your treatment expectations?

Please tick the following boxes that apply to you.

Do you have a Pacemaker

Pregnancy/Breast-feeding

Any forms of Cancer.

Epilepsy

Heart Condition

Diabetes

Inflammation/Infection

Varicose Veins

Moles/Warts

Botox/Dermal Fillers

Over/active thyroid

Skin disorders

Retin A/ roaccutane

Skin lesions cuts/ burns

Metal implant/ IUD

Anti-depressants

Thrombosis/Phlebitis

Tumours

Headaches/ Migraine

Severe muscle conditions

Semi-Permanent Make-up

Severe/Active acne

On hormone replacement therapy

IBS or other bowel conditions.

Multiple sclerosis

Asthma/ breathing problems.

Other:

Add any other medical history or additional comments you would like us to see.

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