Consultation Form

Date of treatment ……………………

Full name ……………………………………………………

Address  

………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Postcode   ………………….   Contact number   ……………………  D.O.B   ……………..

Email Address …………………………………………………………………………………….

TREATMENT PROCEDURE: …………………………………………………………….

MEDICAL INFORMATION AND MEDICATION

Are you currently under the care of a doctor or hospital specialist?    YES / NO

If YES, please give details:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Please list any medication you are taking including any contraceptives (this includes the pill)

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Please circle YES/NO of all conditions that apply to you.

Pregnant yes/no                                 

Cancer yes/no                                 

Lupus yes/no

Eye disorder yes/no                            

Haemophilia yes/no                        

HIV yes/no

Skin disorder yes/no                           

Diabetes yes/no                               

TB yes/no

Hyper pigmentation yes/no              

Dry eye yes/no                                  

Alopecia yes/no

Anaemia yes/no                                  

Hepatitis yes/no                               

Asthma yes/no     

Any additional information of medical conditions not listed above:

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Photographic Release Form

I (please print name) ———————————————- Date ——————-

I consent for my technician to use any of the photographs / videos taken today for promotional purposes on social networking platforms and/or on websites.

Signed Client —————————-        Date —————————————- 

Signed Technician ——————————      Date ———————————-

MODEL FORM

I (please print name) ———————————————- Date ——————-

I understand my artist is currently enrolled onto ongoing training with Blush & Brow Academy as a microblading artist and I give permission for said artist to perform a microblading treatment on me today as part of their portfolio to gain their qualification. I understand the level of work will be that of a student training and release the artist from any liability should the results not be 100% what I asked for. If for any reason I wish to seek treatment from the artists trainer Emma Wright, I understand this will be a chargeable appointment.

Signed Client —————————-        Date —————————————- 

Signed Technician ——————————      Date ———————————-