FACIAL CONSULTATION FORM | Adele Hardcastle

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FACIAL CONSULTATION FORM

Medical Questions

Do you have any allergies or have you experienced any allergic reaction to medicine or products (such as latex, plaster, nickel, etc)? *

Yes

No

Do you feel fit and well and able to have a procedure today? *

Yes

No

Do you have or are you having any injectables or fillers? *

Yes

No

Have you had a Dermaplaning treatment before? *

Yes

No

Have you had an Acid Peel before? *

Yes

No

Do you suffer from haemophilia? *

Yes

No

Do you knowingly have any infectious diseases? *

Yes

No

Do you knowingly have Hepatitis C? *

Yes

No

Do you suffer from shingles? *

Yes

No

Do you suffer from cold sores? *

Yes

No

Do you take blood thinners or anti inflammatories? *

Yes

No

Do you take Antabuse? *

Yes

No

Do you take Roaccutane? *

Yes

No

Do you have high or low blood pressure? *

Yes

No

Are you currently taking any medication? *

Yes

No

Do you have hypersensitive skin? *

Yes

No

Do you have any skin abnormalities, ie eczema, psoriasis etc? *

Yes

No

Do you have or have you suffered from rosacea? *

Yes

No

If you have answered YES to any of the questions, please give further details here

DECLARATION

I understand the importance of my accurate and complete medical history and that withholding any medical conditions may be detrimental to my health and the outcome of the procedure.

I understand that I must adhere to the aftercare advice.

I hereby give my written consent for Adele Hardcastle of The Skin & Brow Clinic to carry out the treatment of my choice.

By ticking below I agree to the above.

I agree

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Eyebrow specialist, Skin & Beauty clinic based in the beautiful village of Nettleham near Lincoln

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Contact Information

Clinic Address

Email Address

10 Cooper Close, Nettleham,

Lincoln,

LN2 2XX

adele.brows@icloud.com

Phone Number

QUICK LINKS

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OPENING HOURS

Monday 10am - 8pm

Tuesday 6pm - 8pm

Wednesday 9am - 12pm

Thursday 9am - 12pm

Friday Closed

Saturday 9am - 1pm

Sunday Closed

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