Microblading Consultation Form

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Title:

Client Name: *

Address: *

Postcode: *

Tel Home:

Tel Mobile: *

E-mail Address: *

Age:

D.O.B *

GP Name & Surgery: *

GP Contact No: *

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MEDICATION

To ensure that you have no adverse reaction to cosmetic treatments it is important for us to know if you are taking any medication. Some medications can sensitize the skin and we may need to obtain your doctors consent before we can proceed with cosmetic treatment.

Are you taking any medication? *

Yes No

Are you currently or have you use Roaccutane, Isotretinoin’s or Retin A in the last 6 months? *

Yes No

Have you taken antihistamines, antibiotics, cold remedies or pain killers in the past 2 days? *

Yes No

If you have answered Yes to any of the above, please list all medication:

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REASON(S) FOR TREATMENT

We strive to provide the best appropriate medical care for all patients requiring aesthetic medical treatments, please can you help indicate by completing the following section your reason for requiring aesthetic medical treatment.

Please tick the following that apply:

I am seeking treatment to improve my appearance My current appearance is causing my mood to be low My current appearance is reducing my confidence when interacting with others If the problem with my appearance is improved - I think my mood will improve If the problem with my appearance is improved - I think my self-confidence will improve If the problem with my appearance is improved - I think that I will feel more confident when interacting with others If the problem with my appearance is improved - I think my self-esteem will improve

I confirm that all the information I have given is accurate to the best of my knowledge and I will ensure that I advise my practitioner of any changes.

Patient Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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