WAIRARAPA REGISTRATION
Referrals to Look Good Feel Better workshops are accepted from Health Professionals only for women receiving any cancer treatment (chemotherapy, radiotherapy, surgery, etc), who have not attended a workshop in the previous twelve months.
HEALTH PROFESSIONALS ARE REQUIRED PLETE THIS SECTION FOR WOMEN WHO MEET THE ABOVE CRITERIA. Please fill in the following information:
Name: ______________________ Professional Role: ___________________ Phone ______________
LADIES please provide the following information: Today’s Date:
Name: (Please print clearly)
Address:
Telephone: (Business) ____________________ (Home) ______________________ Age:
Email Address: __________________________________________________
Look Good Feel Better is a Programme designed to give you confidence and boost your self esteem.
To assist us in providing the best product to suit you, plete all categories:
Ethnic Group: European Pacific Island Maori Asian other __________
Eyes: Grey Black Blue
Dark Brown Green/Hazel Amber/Brown
Skin tone: Very Fair/Pink Fair Medium Dark
Sallow/Golden Olive Dark/Mocha
Skin type: Dry Normal Combination
Eyebrow Colour: Blonde/Ash Light Brown Medium Brown
Dark Brown Grey Black
Hair Colour:
Colour preferences: Eye shadow: ________________ Lipstick: ________________
Hair Loss
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