Consultation Form

First Name

Last Name

Phone

DOB

Select an Address

Are you over 18 years of age?

Do you have any allergies?

Have you experienced any allergic reacations to any products such as latex, plaster or nickel?

Are you allergic to olive oil, beeswax or vitamin E?

Have you had botox, fillers or chemical peels in the last 2/3 weeks?

Do you have any keloid scarring?

Do you have any imminent holidays planned?

Do you suffer from epilepsy and have you had a seizure in the last 2 years?

Do you suffer from Haemophilia?

Do you knowingly have any infectious diseases?

Do you have hepatitis C?

Do you suffer from shingles?

Do you have diabetes?

Have you ever had a reaction to hair dye or brow tint?

Do you have any respiratory problems or illnesses?

Do you suffer from, or have any problems with wound healing?

Do you take blood thinners or anti inflammatories?

Do you take Antabuse?

Do you take Roaccutane?

Do you have high or low blood pressure? if so, please state which.

Do you wear contact lenses?

Do you suffer from glaucoma?

Are you 5 weeks pre or post radiotherapy and/or chemotherapy treatment?

Are you allergic to any local anaesthetics?

Are you currently taking any medciation?

Are you pregnant or breastfeeding?

Are you happy to have photographs taken pre & post treatment for social media & webiste?

Where did you hear about Susan Shaw Microblading? Google/Yell.com/Instagram/Facebook

Please note: You will be required to complete an allergy patch test prior to your appointment, therefore no treatment can go ahead without this being completed.

Susan will be in touch to arrange this.

I understand my condition or medication (if any) may affect the treatment, including bruising, bleeding and additional healing time.

I understand the importance of providing an accurate and complete medical history, and that withholding any information may be detrimental to my health and outcome of the procedure/treatment.

Your Signature

Date

Thanks for submitting!

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Consultation Form

Susan Shaw Microblading Artist