All Portal Forms – Banana Beauty Lab

First Contact - Initial Intake

Customer Details - Initial Intake

BBL - Customer Details - Initial Intake

Patient Information

Please provide the patient's personal & contact details.

First Name

Last Name

Phone no.

Date Of Birth

Address Line 1

Address Line 2

City

Borough / State

Post Code

Country

Next Of Kin Name

Next Of Kin Contact Number

Select Treatment / Service

Medical & Consent Form

BBL - Medical Consent Form Final

Step 1
Step 2
Step 3
Step 4
Step 5

Patient Information

Please provide the patient's personal & contact details.

First Name

Last Name

Prefered Name / Nickname

Address Line 1

Address Line 2

City

Borough / State

Post Code

Country

Phone no.

With whom do you live?

Patient Gender

Patient Age

Date Of Birth

Vitals & Physical Metrics

Please provide current physical measurements.

John this element will go Above the start of Vitals / Physical Metrics Section.

Height

Weight

Spouce Name

Marital Status

Married

Unmarried

Other

Disability ?

Yes

Marital status(other)

Next Of Kin Name

Next Of Kin Contact Number

Employment / Retired

Some description about this section

Occupation

Retired?

Yes

Date of retirement

Date of disability

Doctor & Medical

John Lets think of something to go here.

Who is your Primary Care Doctor:

Phone Number of Primary Care Doctor:

Where is your Primary Care Doctor located:

Allergic to any medications

Yes

Allergic to any medications

Do you smoke?

Yes

How many years did you smoke?

If you quit, when did you stop?

Do you drink alcohol?

Treatment Service

Please select your desired treatment.

Select Treatment / Service

Date / Time

Other Information

Consent & Agreement

Please read and accept the medical consent terms.

I confirm that the above Medical Information is accurate.

And I agree to the Cancellation Policy.

I have read and agree to the Terms and Conditions and Privacy Policy

Form C

Nutritional Consultation

BBL - Form C - Nutrition Consultation Form

Reason for Consultation

Current Medications

Diagnosed Conditions affecting Diet

Diabetes

Coeliac Disease

Irritable Bowel Syndrome (IBS)

Inflammatory Bowel Disease (IBD)

Thyroid Disorders

Allergies/Intolerances

Peanuts

Anethesia

History of Eating Disorder

Yes

Form E

Facials & Waxing

BBL - Form E - Facials & Waxing - Book Appointment

Contact Information

Book Your Appointment & Select your Treatment and preferred time slot below.

First Name

Last Name

Email Address

Phone Number

Treatment & Scheduling

Choose your service category and preferred time slot.

Select Treatment

Preferred Appointment Date & Time

Special Instructions / Notes

Form F

Eyebrows & Eyelashes

BBL - Form F - Eyebrows and Eyelashes

Contact Information

First Name

Last Name

Email Address

Phone Number

Have you had a patch test with us for lash/brow products in the last 6 months?

Yes

Not sure

Patch Test RequiredA free patch test is required 24–48 hours before your treatment. We have converted your submission into a Patch Test Appointment Request. Please select a time below for your quick 5-minute patch test.

Requested Patch Test Date & Time

Select Treatment

Select Practitioner

Practitioner Assigned

Preferred Appointment Date & Time

Global Contact

General Questions & Enquiries

BBL - Contact Form General

Get In Touch

Please use this form for general enquiries

First Name

Last Name

Subject

Practitioner *If Applicable*

Your Message

Botox / Geneo / Oxy

Botox & Geneo OxyGeneo Facial

BBL - Botox & Geneo OxyGeneo Facial - Initial Medical Screening

Initial Medical Screening

Please complete this screening form honestly prior to your Botox or Geneo OxyGeneo Facial treatment.

Are you pregnant or breastfeeding?

Yes

Have you taken Roaccutane or isotretinoin in the last 6 months?

Yes

We may need to postpone. Our team will contact you.

Active acne, eczema, psoriasis, rosacea or dermatitis on the face?

Yes

Details

Cold sores?

Yes

Any skin infections, open wounds or sunburn on the face?

Yes

Botox or filler in the last 2 weeks?

Yes

What and when

Chemical peel, laser or microneedling in the last 4 weeks?

Yes

Currently using retinol, retinoids or exfoliating acids?

Yes

Which products

Do you scar easily or get dark marks after skin trauma?

Yes

Any known allergies to skincare ingredients?

Yes

Details

Sensitive skin or previous reactions to facials?

Yes

Details

Main skin concerns

Client Agreement & Signature

Please confirm your details and sign below.

First Name

Last Name

Date of Birth

Signature

Date

Botox Screening

Botox Medical Screening Form

BBL - Botox Medical Screening Form

Botox Medical Screening Form

Some description about this section

Pregnant, breastfeeding or trying to conceive?

Yes

Textarea

Infection, cold sore or broken skin at the area?

Yes

Unwell, fever or vaccination in last 2 weeks?

Yes

Blood thinners or bleeding disorder?

Yes

Which medication

Autoimmune condition or immunosuppressants?

Yes

Details

History of anaphylaxis?

Yes

To what

Previous injectable complications?

Yes

Details

Events or flights in next 2 weeks?

Yes

Neuromuscular condition e.g. myasthenia gravis?

Yes

Textarea

Aminoglycoside antibiotics or muscle relaxants?

Yes

Which one

Had botulinum toxin before?

Yes

Brand, Areas, Date, Any problems

Eyelid or brow droop after treatment?

Yes

Heavy brows or hooded eyelids?

Yes

Full

name

Date

Textarea

Booking / Temp / Tests

Mona's Facial & Skin Treatment

Book An Appointment / Treatment

John / Mona Test This form.

BMI Calculator

BBL - BMI Calculator Form

Gender

Male

Female

Age

Height (feets)

Weight (pounds)

Weight (Kg)

Height (meters)

Body Mass Index

Body Fat Percentage

First Contact - Initial Intake

Customer Details - Initial Intake

Patient Information

Medical / Consent

Medical & Consent Form

Patient Information

Vitals & Physical Metrics

Employment / Retired

Doctor & Medical

Treatment Service

Consent & Agreement

Form C

Nutritional Consultation

Form E

Facials & Waxing

Contact Information

Treatment & Scheduling

Form F

Eyebrows & Eyelashes

Contact Information

Global Contact

General Questions & Enquiries

Get In Touch

Botox / Geneo / Oxy

Botox & Geneo OxyGeneo Facial

Initial Medical Screening

Client Agreement & Signature

Botox Screening

Botox Medical Screening Form

Botox Medical Screening Form

Booking / Temp / Tests

Mona's Facial & Skin Treatment

Book An Appointment / Treatment

BMI Calculator

BMI Calculator

Aesthetics

Facials

Massages

Brows & lash

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