CLIENT CONSULTATION FORM

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First Name

Last Name

Address

Email

contact number

MEDICAL HISTORY please tick where applicable

heart condition/stroke

severe circulation disorder

skin disorder

kidney disorder

swelling/oedema/haemophilia

cancer

limitation of body movement/arthritis

prone to scarring

hormone imbalance

claustrophobia

hepatisis

metal plates/pins/piercings

recent scar tissue or operations within the last 6 months

allergies

respiratory issues

are you pregnant

high/low blood pressure

epilespy

are you applying any topical or oral steriods ie retinals or roaccutane

if you have received a patch test for lash tinting/LVL/lash extentsions did you have an allergic response? please tick if yes

Date

I confirm that the information given in this form is true

intials to confirm

Thanks for submitting!