Client Consultation Form

First Name

Last Name

Email

Phone

Date of birth

Address

Emergency Contact

Emergency Phone

Emergency Contact Relationship

What service are you applying for? What service are you applying for? Ombre Brows ($699) Eyebrow Feathering ($699) 6-12 Month Colour Refresh ($199) 18-24 Month Colour Refresh ($399)

Please describe the results you are after

Have you had any previous cosmetic tattoos in the area you are having treated today? Have you had any previous cosmetic tattoos in the area you are having treated today? Yes No

If yes, please give details

Are you currently receiving any treatment from a doctor or specialist? Are you currently receiving any treatment from a doctor or specialist? Yes No

If yes, please give details

Are you taking any medication, supplements or herbal remedies? Are you taking any medication, supplements or herbal remedies? Yes No

If yes, please give details

Have you had any previous surgery or been admitted to hospital? Have you had any previous surgery or been admitted to hospital? Yes No

If yes, please give details

Please indicate if you suffer from any of the following conditions Please indicate if you suffer from any of the following conditions Heart problems Jaundice/Hepatitis Epilepsy/Blackouts Melasma (pigment changes in the face) Diabetes Keloids Blood disorders Moles (Melanoacytic, Naeu/Melanoma) Recent scar tissue Sunburn Bruises Cuts / abrasions Eczema Psoriasis Acne Skin disorders / diseases Albinism / Vitiligo Port wine stains/ Strawberry birthmarks Pigment birth marks Cold sores Psychiatric illness / Depression HIV Unidentified oedema Unidentified lumps Heart disease Thyroid problems Arthritis Asthma / bronchitis Convulsions Stomach ulcers Glaucome / cataracts Bells palsy Hypoglycaemia Phlebitis / Blepharitis Any other communicable disease Any other autoimmune disease

Are you currently pregnant or breastfeeding? Are you currently pregnant or breastfeeding? Yes No

Do you smoke? Do you smoke? Yes No

Do you suffer from any allergies? Do you suffer from any allergies? Yes No

If yes, please give details

Have you ever had an allergic reaction to any beauty treatment including injectables? Have you ever had an allergic reaction to any beauty treatment including injectables? Yes No

If yes, please give details

Do you suffer from any autoimmune diseases? Do you suffer from any autoimmune diseases? Yes No

If yes, please give details

Are you taking any Acne medication? Are you taking any Acne medication? Yes No

Have you been treated with Botox in the face in the last 2 weeks? Have you been treated with Botox in the face in the last 2 weeks? Yes No

Have you been treated with Chemotherapy or Radiation in the past 12 months? Have you been treated with Chemotherapy or Radiation in the past 12 months? Yes No

Is there any other aspects of your health that you think we should know about?

I confirm I will NOT consume alcohol in the 24 hours leading up to my appointment I confirm I will NOT consume alcohol in the 24 hours leading up to my appointment Yes No

I confirm I will not use any Retinol based skin products 4 weeks prior to my appointment I confirm I will not use any Retinol based skin products 4 weeks prior to my appointment Yes No

I confirm I will not use any Hair Growth Serum in the area 4 weeks prior to my appointment I confirm I will not use any Hair Growth Serum in the area 4 weeks prior to my appointment Yes No

The topical anaesthetic used may contain Tetracaine, Lignocaine, Prilocaine and Epinephrine. Do you give your approval for these creams and gels to be used during your procedure? The topical anaesthetic used may contain Tetracaine, Lignocaine, Prilocaine and Epinephrine. Do you give your approval for these creams and gels to be used during your procedure? Yes No

I certify that tattooing will only begin once I have approved that the shape and design I love has been drawn on. I certify that tattooing will only begin once I have approved that the shape and design I love has been drawn on. Yes No

Do you approve of The Beauty Loft by Mandy using photos or videos of the treatment in advertising and on social media? Do you approve of The Beauty Loft by Mandy using photos or videos of the treatment in advertising and on social media? Yes No

What is the colour of your eyes? What is the colour of your eyes? Blue Blue, Green, Brown Dark Brown Brownish Black

What is the colour of your natural hair? What is the colour of your natural hair? Sandy Red Blonde Chestnut / Dark Blonde / LightBrown Brown Black

What is the colour of your skin? (non exposed areas) What is the colour of your skin? (non exposed areas) Reddish / Pink Very Pale Pale with Beige Light Brown Dark Brown

Do you have freckles on unexposed areas? Do you have freckles on unexposed areas? Many Several Few Incidental None

To what degree do you burn if you were to stay in the sun too long? To what degree do you burn if you were to stay in the sun too long? Burn and peel easily Burn followed by peeling Burns then tans Rarely burns Never burns

How often do you get sun exposure? How often do you get sun exposure? Never Hardly Ever Sometimes Often Always

When did you last expose your face to the sun or solarium?

How did you hear about us? How did you hear about us? Instagram Facebook Referral Google Other

Please attach a CLEAR photo of your full face with no makeup or eyebrow tint to ensure suitability File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, png, heic. Max. file size: 1 MB

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