Patch Test Declaration Form

    Basic Information

    • Please give your full name
      Please fill this in
    • Please give your email address
      Please fill this in
    • Date of Birth
      Please fill this in
    • Mobile number
      Please fill this in
    • Patch test received?
      Please fill this in
      • Tint
      • Lash Lift



      Please can you make sure all the information given above is correct, true and up to date. At the Norfolk Mead Hotel treatment rooms, we will not be held responsible for any consequences of being given false information or no information at all, which may affect specific treatments. All treatments are for general purposes and not intended for substitution of medical procedures. 

      Please note: We will never share your personal information with any 3rd parties and all information supplied will only be used for the purpose of your treatment, All personal information is only accessible to our Therapists and Reservation teams. You may view your personal file at any time via our Therapists. 

    • Name
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    • Date
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