Consultation Form Step 1 of 4 25% Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email* Mobile* DOB* DD slash MM slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Name* Emergency Contact Phone* Do you have any permanent makeup or tattoo in the area to be treated?*-YesNoWhen and by who*Are you coming for a brow tattoo correction*YesNo Have you ever had an allergic reaction to any of the following* Lidocaine Latex Rubber Lanolin Novocain Dental Injection Metals Foods PABA Other Drugs Other NONE OF THE ABOVE Other Allergic Reactions? Describe the reaction*Have you got any of the following?* Cold Sores Fever Blisters Mouth Ulcers Herpes NONE OF THE ABOVE How have you been treating this?*Do any of the following apply: Smoker Seizures High blood pressure or low blood pressure Diabetic Type 1 Diabetic Type 2 Used or using Retin A / Acutane / AHA / Glycolic products Prone to Keloid or hypertrophic scar Wear a pacemaker Sensitivity to makeup products Pregnant or nursing a baby Taking blood thinners Undergoing IVF treatment Depression Autoimmune Disorders such as HIV Hemophilia or any blot clotting disorders Anemic Planning cosmetic or other surgery in the near future Any skin disorders such as eczema, psoriasis, skin cancer Recent injuries and surgeries Bruise or bleed easily Experienced hair loss Laser or IPL Botox or collagen Injections Tinted Eyebrows or Eyelashes Type 1 Diabetics Please bring a letter from your doctor confirming that your diabetes is under control and its ok to have this procedure Haemophilia/blod clot Please bring a letter from your doctor confirming that your haemophilia/blod clotting is under control and its ok to have this procedure List any medication, Prescriptions and non prescription that you have taken in the last 2 weeks:*Skin Type*[1] White - Always burns, never tans[2] White - Mainly burns, sometimes tans[3] White - Sometimes mild burns, average tans[4] Moderate Brown - Rarely burns, tans with ease[5] Dark Brown - Very Rarely burns, tans very easily[6] Black - Never BurnsEthnic Background (Parents/Grandparents)Consent* I acknowledge the above information to be true and correct.It is the clients responsibility to keep the therapist informed of any changes in health, lifestyle medication etc.. By signing this form the client is agreeing that the information given is true and correct to the best of their knowledgeSignature*