pre-treatment Consultation & consent Form
Please complete this form honestly and to the best of your knowledge.
PLEASE NOTE: IF YOU ARE PREGNANT OR BREASTFEEDING,
YOU CANNOT HAVE ANY BROW TREATMENTS.
1. CLIENT DETAILS
2. MEDICAL HISTORY
Please enter X for any conditions that apply to you from the following list.
Local Anaesthetic Allergy
Other Allergies, please specify
Blood Thinning Medication
3. CURRENT MEDICATION
4. PREVIOUS COSMETIC TREATMENTS
5. PATCH TEST
A patch test must be carried out using the pigment, primary and secondary topical local anaesthetic (numbing cream) intended for your treatment.
Please complete the information below. Your treatment cannot proceed unless you confirm that you have had 'no adverse reaction' to the patch test.
6. PRE-TREATMENT INFORMATION
I understand I must avoid alcohol for 24 hours before treatment.
I understand I should avoid asprin and ibruprofen for 48 hours, unless prescribed.
I understand I should avoid caffeine 24 hours before treatment.
I understand I should avoid excessive sun exposure including sun beds before treatment.
I understand I should avoid eyebrow treatments such as waxing, tinting or threading my brows immediately before treatment.
I understand I must inform Susan Shaw if my medical history change before my appointment.
7. RISKS & CONSENT
I understand results may vary between individuals
I understand the price includes a top up and I will attend the top up appointment within 6 weeks of initial appointment.
I understand healed colour cannot be guaranteed.
I understand redness, swelling and flaking are normal.
I agree to follow aftercare instructions issued by Susan Shaw
I understand infection can occur if proper care is not taken, good hygiene and aftercare not followed.
I understand I may need colour refreshes may be required due to natural fading.
I have had full opportunity to ask Susan Shaw questions.
I voluntarily consent to treatment.
8. PHOTOGRAPHY CONSENT
If you select YES for marketing/social media, I understand my name and personal details will never be published.
9. GDPR CONSENT
I consent to Susan Shaw securely storing my personal information for treatment records, insurance purposes, appointment administration and legal compliance in accordance with GDPR.
10. CLIENT DECLARATION
I confirm that the information above is true and accurate.
I Understand that I must inform Susan Shaw immediately if I develop an adverse reaction from the patch test, for example, any redness, swelling, itching, blistering before my appointment.
I understand my condition or medication (if any) may affect the procedure, including bruising, bleeding, soreness & redness around the brow area.
