Client Consultation - Brow & Lash Name * First Name Last Name Date of birth MM DD YYYY Phone number * Email * Please tick if you have any of the following conditions: * If you tick any, treatment CANNOT be performed Alopecia Cataract Chemotherapy Conjunctivitis Dermatitis Diabetic Dry Eye Syndrome Eczema Eye Surgery (Recent) Glaucoma Laser Hair Removal (Recent) Pregnant (Currently) Psoriasis Retinopathy NONE OF THE ABOVE Please specify condition if you have ticked any of the above Please tick if you have any of the following * If you tick any, treatment MAY be performed Accutane Allergies Anxiety Claustrophobia Contact Lens Hypersensitivity On Medication Skin treatments (within the last month) Use of actives (AHA, BHA, Vitamin A) NONE OF THE ABOVE Please specify if you have ticked any of the above Consent for photography I consent to have photos taken of my brows and/or lashes I consent to have videos taken of my brows and/or lashes Consent for treatment * I hereby authorise for the trained technician at Rebecca Brows and Lashes, formally trading as Rebecca Skin Health (ABN: 46866701107) to perform the lash and/or brow treatments on me. I am over 18 and have given the correct details and history information about me and I accept full responsibility. I have read, understood and will follow all the aftercare information given to me, and I am responsible for all general care of my lashes and/or brows. Today's date MM DD YYYY Thank you!
