Please fill in your details for all the fields marked * to enable your registration to be completed.
You do not need to be referred to register for a class.
If you need any help completing your registration please call 0800 865 432.

Contact Details

First Name

Last Name

Email

This will be used to send class details, so please make sure it is the Contact's email address.

Mobile Phone

02XXXXXXXXX

Phone

Preferred Contact Method

Street No. & Name

City

Postcode

Date of Birth

dd/mm/yyyy

Ethnicity

For what type of cancer are you being treated?

Have you experienced hair loss?

The following information assists us in providing the best products to suit you in your kit of donated skincare and makeup. Please complete all categories

Skin Tone

Eyebrow Colour

Eye Colour

Hair Colour

Preferred Lipstick Shade

Preferred Eyeshadow Shade

Have you ever attended a LGFB Look Good Feel Better class before, either in the community or online?

How did you hear about Look Good Feel Better?

Would you like to bring a Support Person?

Support Person Name & Contact Details (Mobile/Email)

Are there any products/brands that you should not use for health or medical reasons (including reasons related to your treatment)?

Any special requirements eg wheelchair access?

We like to thank the wonderful people who share our services with their patients and customers. If you know the details of this person, please complete below. Not a problem if you don’t know, or were not referred – please leave blank.

Referrer/Health Professional Name

Referrer/Health Professional Email

Leave blank if email is not known

Please be aware that cosmetic, make-up and skincare products are provided and used at Look Good Feel Better classes. Look Good Feel Better is non medical and those wishing to attend a Look Good Feel Better class should consult their oncologist if they have any concerns regarding the products we use. A list of the brands donated is available on our website. The Cosmetic, Toiletry and Fragrance Association of New Zealand (CTFA) and member companies take their responsibility for the safety of cosmetics and toiletries very seriously. Safety substantiation of ingredients, either by manufacturers of raw materials, or by companies marketing products containing them, is based on rigorous scientific safety processes. Legislation requires any cosmetic product placed on the market to be safe under normal circumstances of use. Please read our Privacy Policy for more information on how we use your information.

Thank you for taking the time to provide us with information that will help us ensure you get the most out of your Look Good Feel Better experience. If you have any questions please call 0800 865 432

Contact Details

Personal Details

Registration Details