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General information

Please complete the questions below to assist us in ensuring your rejuvenation journey is carefully curated for your individual needs and considers any relevant history or conditions for your treatment plan. Please only complete sections you are comfortable sharing with us at this stage:

First Name

Surname

Todays date

ID Number

Date of birth

Gender

Email

Mobile Phone

Address line 1

Address line 2

City & Country

Postal code / Zip code

What size gown would you prefer?

What size shoe are you?

Please tell us how you found us?

YOUR LIFESTYLE:
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What are your main aesthetic and health concerns & existing conditions and for how long have you experienced it?

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Have you had any previous surgery? If so please specify and at what age?

Are there any medical conditions or cause of death in your direct family history (eg heart attack)?

Have you had blood drawn within the last 6 months ? If so where?

Please specify your current medications, supplements and dosage.

Do you smoke/Vape? How many cigarettes/how often per day?

Do you suffer from any of these conditions:
Anxiety, Depression,Chronic fatique, Headaches, Migraine, Cluster Headaches, Firbomyalgia, Asthma,Cancer, Psoriasis, Eczema, Hay fever, Cholestrol abnormalities, Cardiac Disease, Cardiac Arithmia's, Stroke history, Facial or muscular paralysis ,Diabetes, Epilepsy, Hypertension, Hypotension, Circulatory Disorder, Limphatic disorders or clearance issues, COPD, Hepatitis, Fatty liver disease, KidneyStones, Gout, Diverticulitis, Constipation, Lung disease, HIV, Renal Disease,Gallstones, Chron's Disease, Ulcerative Colitis, Spastic Colon, IBS, Leaky gut syndrome, Tetanus, Malaria, Thyroid abnormalities, Porphyria, Tick Bite Fever,Skin Infections of any type, Skin grafts or reconstructive procedure history, other

Please specify below if any of the above apply. This may influence which treatments are/are not suitable for you:

What work do you currently do?

How many hours per week?

Are you married?

Do you have children? How many and what ages?

Your Skin

Your Body

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation inaccurate information may result in including, but not limited to, contraindications and/or irritation to the skin/body from any treatments received or any after-treatment products and/or recommendations received. I am aware there are often inherent risks associated with skin/body the treatments and/or after-treatment products or recommendations provided by Terre Paisible (Pty) Ltd and that any products or services I am about to receive provided by Terre Paisible (Pty) Ltd may not have the desired results. I also acknowledge that I have been made aware that any treatments and/or after-treatment products and/or recommendations may lead to unintended effects could have unfavorable results including, but not limited to: allergic reactions, irritations, burning, redness, scarring, soreness, etc. By signing below, I further agree that I will not hold Terre Paisible (Pty) Ltd, its owners, affiliates, any of its employees, contractors or suppliers responsible should there be any unfavorable outcome or result, personal injury, mental anguish, damage or loss of any kind whatsoever caused during and after such treatments, products or services performed or received by Terre Paisible (Pty) Ltd.

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