Lash and Brow Consultation Forms

Client Contact Details

First name

Last name

Address

Email

Phone

Age

Emergency Contact Details

Emergency Contact Name

Emergency Contact Telephone

GP Details

Medical Details

Have you been under medical care in the last 6 months?

Yes

No

If yes please provide details

Have you undergone surgery within the last 6 months?

Yes

No

If yes please provide details

Please list any medications, diuretics, supplements, vitamins that you take regularly

Within the last 6 months have you had any medically prescribed acne products e.g. Roaccutane / Retinol / Retain A / Retinova / Tarozac / Other?

Yes

No

Please list any ongoing health concerns

Please list any allergies, including reactions to hair dye

Please confirm if there is any bruising, swelling, broken skin or bones that have been fractured within the last 6 months in/around the area(s) being treated.

Please confirm if you have any infectious or non-infectious conditions presenting in or around the areas being treated

Do you suffer with any neck or spinal injuries?

Yes

No

Do you experience any pain? If so please provide details

Lifestyle

Do you wear glasses or contact lenses?

Yes

No

I am aware that contact enses cannot be worn during the treatment or immediately after

Have you had permanent make-up applied within the last 4 weeks?

Yes

No

I am aware that I should not have permanent make-up applied within 4 weeks prior to my treatment

Have you had botox (or equivalent) or dermal fillers within the last 4 weeks?

Yes

No

I am aware that I should not have botox or dermal fillers within 14 days prior to my treatment

Have you recently applied fake tan?

Yes

No

I am aware that I should not apply fake tan for 72 hours before or after my brow tint / henna treatment

Are you using skincare that contains AHAs (i.e. glycolic acid, lactic acid), BHAs (i.e. salicylic acid) or vitam A (i.e. retinol, retinoids including tretinoin)?

Yes

No

I am aware that I should avoid using skincare products with these ingredients for at least 72 hours prior to and following my treatment

How often do you go swimming or use a sauna?

I am aware that I should avoid getting my lashes / brows wet for at least 24 hours following treatment and should avoid steam and saunas for at least 48 hours

Are you currently ... (please tick all that apply)

Pregnant or trying to become pregnant

Breastfeeding

Clients Objectives

What are your main concerns with your lashes / brows?

What would you like to achieve from your upcoming treatment?

I understand that successful completion of a patch test does not guarantee that an allergic reaction will not occur

I am aware that I should not wear eye make-up before the appointment and for 24 hours after

I am aware I should condition my lashes / brows daily following treatment in order to prolong

Lash and Brow Consultation Form

This form should be completed prior to your first appointment, when it has been longer than 6 months between appointments or when there has been a significant change to your medical history or lifestyle that could impact upon your Lash or Brow treatments.

Client Contact Details

Emergency Contact Details

Medical Details

Lifestyle

Clients Objectives

Mobile Services

Rejuvenation Clinic