Consultation, Patch Test and Consent Form
In order to give you the safest , most suitable treatment, please take a moment to fully complete this consultation form. If at any stage the information you have provided changes, please let us know so we can update your file.
Email address *
Date of birth *
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Full name *
Address *
Phone number
Are you currently using, or have in the past, any of the following: Retin-A, Renova or Accutane *
Skin thinning products and/or drugs? *
Sun beds? *
Are you pregnant or breastfeeding? *
Are you currently taking any medications? *
Do you have any allergies ie, aromatherapy, nut, hair dye, tint, henna tattoo etc? *
Have you ever had a reaction to a product? *
Have you had any recent surgeries? *
Please List any other illness/condition you are currently being treated by a medical professional *
Declaration
I have read the above information and if I have any concerns, I will address these with my therapist. I give permission to perform the procedure we have discussed and will hold her harmless from any liability that my result from this treatment. I have given an accurate account of the questions asked about including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand that my therapist will take every precaution to minimize or eliminate negative reactions as much as possible. Waxing does have certain side effects such as redness, bruising, tenderness etc. although this is rare. I am agreeing to patch testing at least 48 hours before my appointment and will inform my therapist immediately if I experience irritation or allergy. I understand that I may still experience allergic reaction, sensitivity and irritation from the service(s) tinting/waxing/brow lift/lamination/lash lift. Allergic reaction is rare but can be severe. I understand that any person can develop an allergy to an substance at any time so prior tinting/waxing/brow lift/lamination/lash lift are not a guarantee that no allergy exists. I am willing to follow recommendations made for a homecare regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or aftercare, I will consult my therapist immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand that above paragraph and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and except the risks. I do not hold the therapist responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed.
Patch Test(s) *
Required
Please sign and date *
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