REGISTRATION.doc


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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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  • 页数1
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  • 上传人cjc201601
  • 文件大小72 KB
  • 时间2018-06-15