Eyelashes Consent Form - Mary Beauty Clinic

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Eyelashes Consent Form

Step 1 of 7

14%

Name(Required)

First Last

Date of Brith(Required)

Day

Month

Year

If You Complete the From on Behalf(Required)

First Last

Relation To Client(Required)

Contact Number (Mobile)(Required)

Contact Number (Land Line)

Email

Address & Postal Code(Required)

FirstLine Second Line City Post Code

Occupation(Required)

Do You Have WhatsApp?(Required)

Yes

No

Best Way to Contact You?(Required)

Call

SMS

WhatsApp

Email

Please read and complete this form carefully.

Please indicate your answer by checking one box per question and provide detail where appropriate.

To the client:

You have the right to be informed about the procedure(s) to be administered, including benefits, risks, and potential side-effects, so that you can decide whether to proceed. You are encouraged to ask any questions you may have and to consult with a therapist if you have additional questions.

1.Are you pregnant or breastfeeding?(Required)

Yes

No

2.What is your Eyelashes length?(Required)

Short

Medium

Long

3.What is your Eyelashes thickness?(Required)

Thin

Medium

Thick

4.What are your Eyelashes colour?(Required)

Black

Brown

Blonde

Tinted

5.Do you have had any of the following

Noun

Alopecia

Cataract

Dry eyes syndrome

Recent eyes infection

Psoriasis around the eye area

Conjunctivitis

Eczema

Sensitive eyes

Diabetic retinopathy

Glaucoma

Trichotillomania

Wear contact lenses

Allergy to latex

Allergy to plasters

Any other Allergies

Please Explain:

Refrain from:

Touching the treated area
Using soaps, cleansers, creams or make-up on the treated area for 5 days
Facial treatments - including eyelash or eyebrow tinting or tweezing, electrolysis. waxing etc.
Any abrasive products, rough towels or similar
DO NOT TOUCH or PICK the small scabs that may appear after the treatment. Healing will take up to one week, and it is perfectly normal for the treated area to scab/flake. These scabs/flakes will fall off within a few days.
Taking hot baths, saunas, or any other heat treatments. The treated area should be kept as dry as possible.
Sunbathing, using sun beds or swimming
Using any form of bleach or depilatory products
Should an infection occur, seek medical attention
Expose the treated area to UV rays
Use make-up other than the recommended after care products
Going for any Laser or IPL treatments

Microneedling Consent form(Required)

I understand that results may vary between individuals.

I understand that although I may see a change after my first treatment.

I understand I may require a series of sessions to obtain my desired outcome.

The procedure and its side effects have been explained to me. I understand the benefits and disadvantages of this procedure.

I am advised that although goods are expected, the possibility and nature of complications cannot be accurately advised and there can be no guarantee expressed or implied to the success of the treatment. I am aware that the Dermal pen microneedling treatment is not permanent and that natural degradation will occur over the time.

I agree that I have read (or it has been read to me), I understand this consent form and the information contained in it.

I have had the opportunity to ask any questions about the treatment, including risks, and I acknowledge that all of my questions about procedure have been answered to my satisfaction.

I understand that this procedure is purely elective.

Terms of Service(Required)

I Understand that I am responsible for notifying the beauty therapist if any of the information should change before treatment.
I confirm that the information is true to be best of my knowledge. I have been fully informed about the expected results and effects of my treatment and agree to follow all aftercare advise provided by therapist. I acknowledge that all information is confidential and will be held on file for 7 years, being solely for the purpose and use of my therapist. I hereby give my consent to proceed with treatment.
I understand and agree that all services rendered are charged directly to me and I am personally responsible for payment. I further agree in the event of non-payment, to bear the cost of collection, and/or Court cost and reasonable legal fees, should this be required. By signing below, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.
Under fake not to make a claim against the therapist and salon and do hereby indemnify and hold the said business, its Owner and Employees harmless in respect of any claim or damage suffered by me in the consequence of undergoing the treatments procedure.

I agree to the Terms of Service

Printed Name(Required)

First Last

Guardian Printed Name(Required)

First Last

January 10, 2025

Unique ID

Client Signature(Required)

Guardian Signature(Required)

Where did you hear about the clinic?

Recommendation

Advert

Social media

Other

other

I would like to be notified of any upcoming offers or promotions:

YES! I love it!

No, Thank you

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