Brow Lamination Consultation Card – Christchurch Beauty

First Name

Last Name

Date of Birth

Age

Phone

Email

Address & Postcode

GP Name

GP Phone

Have you ever had an allergic reaction? YesNo

Have you had any surgery recently? YesNo

Do you take medication? YesNo

Do you have any broken skin? YesNo

Do you have any skin conditions pertaining to area being treated? YesNo

Have you been offered a patch test? YesNo

Do you accept liability to go ahead with tinting without patch test? YesNo

Are you pregnant? YesNo

Do you have or have you ever suffered from:
High/low blood pressuredepressive illnesspace makerepilepsy/fitspanic attacksstrokeanxietydiabetesmigraine/headachesasthmaheart diseasepregnancyoperation in the last 6 monthsphlebitisinfections illnessdysfunction of the nervous systemvaricose veinslocalised inflammationbruisingopen woundsscar tissueswellingarthritisOther

I have read, understood and agree with the before/after care instructions: Yes

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