LASH & BROW ENHANCEMENT

LASH & BROW ENHANCEMENT

Microneedling Consultation & Consent

Please read the following information carefully before proceeding with the eyebrow and facial treatment provided by Lash & Brow Enhancement. By signing this form, you acknowledge that you have read, understood, and agree to the terms and conditions outlined below.

Purpose of Treatment:The eyebrow and facial treatment offered by Lash & Brow Enhancement aims to enhance the appearance and condition of your eyebrows and skin. The specific details of the treatment will be discussed with you prior to the session.Potential Risks and Side Effects:While Lash & Brow Enhancement takes all necessary precautions and uses high-quality products, it is essential to be aware that certain risks and side effects may be associated with the eyebrow and facial treatment.

These may include but are not limited to:

A. Allergic reactions to products used during the treatment.

B. Skin irritation, redness, or swelling.

C. Infection if proper aftercare instructions are not followed.

Unsatisfactory results or changes in appearance. Suitability and Pre-existing Conditions:You must inform the technician at Lash & Brow Enhancement of any pre-existing medical conditions, allergies, or sensitivities that may affect your suitability for the eyebrow and facial treatment. This includes any medications or treatments you are currently undergoing.Aftercare Instructions:To ensure optimal results and minimize the risk of complications, it is essential to follow the aftercare instructions provided by Lash & Brow Enhancement. These instructions may include avoiding direct sunlight, refraining from touching the treated area excessively, and using recommended skincare products.

Consent and Release:By signing below, you acknowledge that you have been fully informed about the eyebrow and facial treatment offered by Lash & Brow Enhancement, including the risks, side effects, and aftercare instructions. You consent to undergo the treatment and release Lash & Brow Enhancement, its employees, and representatives from any liability arising from the treatment, except in cases of negligence or misconduct.

I have read and understood the information provided in this disclosure form. I consent to undergo the eyebrow and facial treatment offered by Lash & Brow Enhancement and agree to follow the aftercare instructions.

Microneedling Consultation & Consent Form

1.) First Name *

2.) Last Name *

3.) Phone *

4.) Email *

5.) Date of Birth *

6.) Address *

7.) City *

8.) State *

9.) Zip Code *

10.) Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Emergency Contact Information

11.) Emergency Contact *

12.) Emergency Contact Relationship *

13.) Emergency Contact Number *

14.) Please indicate if you would like updates regarding reminders, offers and products in the future via EMAIL (you can unsubscribe at anytime).

Yes

15.) Please indicate if you would like updates regarding reminders, offers and products in the future via SMS (you can opt-out at anytime).

Yes

16.) Please indicate if we are able to use your photograph for advertisement purposes:

Yes

Medical History

17.) Current condition requiring treatment:

18.) Do you have any known allergies? If Yes, please give details:

19.) Are you currently experiencing any of the following skin conditions?

Papulopustular rosacea
Acne vulgaris stage IIIIV
Herpes simplex
Dermatomyositis
Warts
Scleroderma
Pemphigus/pemphigoid
Bacterial/fungal Infections
Open lesions
Solar keratosis
Skin cancer
No elements found. Consider changing the search query.
List is empty.

20.) Have you ever experienced any adverse reaction to any form of anaesthetic?

Yes

21.) Are you currently under medical supervision for any of the following?

None
Cardiac conditions/ arrhythmia
Auto-immune disorder
Haemophilia
Hepatic disease
Diabetes (I or II)
Cancer
Congenial or idiopathic ethemoglobinemia
Pseudo cholinesterase deficiency
AIDS / HIV
No elements found. Consider changing the search query.
List is empty.

22.) Are you currently pregnant or breastfeeding?

Yes

23.) Are you currently taking (or have taken in the last 3 months) any of the following medications or supplements?

None
Isotretinoin (including but not limited to Roaccutane®/Accutane®/Isotane®)
Anti-coagulants/blood thinners (including but not limited to Warfarin or aspirin)
Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics)
Contraceptive pill
Fish oils/plant oils/omega 3s
Ginseng/gingko biloba/St Johnʼs wort
No elements found. Consider changing the search query.
List is empty.

24.) Have you had any of the following procedures in the last 2 weeks on the area to be treated with microneedling?

None
Plastic/Cosmetic surgery
Muscle relaxant/wrinkle injections (including but not limited to Botox®, DysportTM or Xeomin®)
Dermal Fillers (including but not limited to Juvederm®, Restylane®, Belotero®, Captique® Esthelis®, Radiesse®, Aquamid®, Sculptra® or Artefill®)
Microdermabrasion
Chemical peel (including but not limited to glycolicacid, lactic acid, mandelic acid or salicylic acid)
Derma blading/derma planing
Laser/IPL rejuvenation/hair removal
Radio Frequency (RF) skin tightening
Photo dynamic therapy (PDT)
Dermabrasion
Deep chemical peel
Tattooing/cosmetic tattooing
Electrolysis/diathermy
Hair removal (including but not limited to waxing, sugaring, plucking, threading or depilatory cream)
Spray/self-tanning
No elements found. Consider changing the search query.
List is empty.

I have completed the microneedling Clinical Treatment Consultation & Consent Form honestly and to the best of my knowledge. My microneedling practitioner has provided me with a microneedling PreTreatment Form and a microneedling Post-Treatment Form and has thoroughly explained to me:

• What a microneedling clinical treatment is
• How a microneedling clinical treatment works
• Expected outcomes of my microneedling clinical treatment
• Microneedling clinical treatment contraindications and considerations • Anaesthesia protocols
• Post-treatment care

A fresh needle will be opened in front of you, then used by your practitioner for every microneedling treat- ment. I understand that a course of microneedling clinical treatments will be required for optimum results.

25.) Patient signature

Clear

26.) Patient signature date

27.) Practitioner signature

Clear

28.) Practitioner signature date

Website

LASH & BROW ENHANCEMENT

Microneedling Consultation & Consent

Purpose of Treatment:The eyebrow and facial treatment offered by Lash & Brow Enhancement aims to enhance the appearance and condition of your eyebrows and skin. The specific details of the treatment will be discussed with you prior to the session.Potential Risks and Side Effects:While Lash & Brow Enhancement takes all necessary precautions and uses high-quality products, it is essential to be aware that certain risks and side effects may be associated with the eyebrow and facial treatment.

These may include but are not limited to:

A. Allergic reactions to products used during the treatment.

B. Skin irritation, redness, or swelling.

C. Infection if proper aftercare instructions are not followed.

Unsatisfactory results or changes in appearance. Suitability and Pre-existing Conditions: You must inform the technician at Lash & Brow Enhancement of any pre-existing medical conditions, allergies, or sensitivities that may affect your suitability for the eyebrow and facial treatment. This includes any medications or treatments you are currently undergoing.Aftercare Instructions:To ensure optimal results and minimize the risk of complications, it is essential to follow the aftercare instructions provided by Lash & Brow Enhancement. These instructions may include avoiding direct sunlight, refraining from touching the treated area excessively, and using recommended skincare products.

Consent and Release:By signing below, you acknowledge that you have been fully informed about the eyebrow and facial treatment offered by Lash & Brow Enhancement, including the risks, side effects, and aftercare instructions. You consent to undergo the treatment and release Lash & Brow Enhancement, its employees, and representatives from any liability arising from the treatment, except in cases of negligence or misconduct.

Microneedling Consultation & Consent Form

1.) First Name *

2.) Last Name *

3.) Phone *

4.) Email *

5.) Date of Birth *

6.) Address *

7.) City *

8.) State *

9.) Zip Code *

10.) Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Emergency Contact Information

11.) Emergency Contact *

12.) Emergency Contact Relationship *

13.) Emergency Contact Number *

14.) Please indicate if you would like updates regarding reminders, offers and products in the future via EMAIL (you can unsubscribe at anytime).

Yes

15.) Please indicate if you would like updates regarding reminders, offers and products in the future via SMS (you can opt-out at anytime).

Yes

16.) Please indicate if we are able to use your photograph for advertisement purposes:

Yes

Medical History

17.) Current condition requiring treatment:

18.) Do you have any known allergies? If Yes, please give details:

19.) Are you currently experiencing any of the following skin conditions?

Papulopustular rosacea
Acne vulgaris stage IIIIV
Herpes simplex
Dermatomyositis
Warts
Scleroderma
Pemphigus/pemphigoid
Bacterial/fungal Infections
Open lesions
Solar keratosis
Skin cancer
No elements found. Consider changing the search query.
List is empty.

20.) Have you ever experienced any adverse reaction to any form of anaesthetic?

Yes

21.) Are you currently under medical supervision for any of the following?

None
Cardiac conditions/ arrhythmia
Auto-immune disorder
Haemophilia
Hepatic disease
Diabetes (I or II)
Cancer
Congenial or idiopathic ethemoglobinemia
Pseudo cholinesterase deficiency
AIDS / HIV
No elements found. Consider changing the search query.
List is empty.

22.) Are you currently pregnant or breastfeeding?

Yes

23.) Are you currently taking (or have taken in the last 3 months) any of the following medications or supplements?

None
Isotretinoin (including but not limited to Roaccutane®/Accutane®/Isotane®)
Anti-coagulants/blood thinners (including but not limited to Warfarin or aspirin)
Photo-sensitisers (including but not limited to anti-depressants/anti-anxieties/antibiotics)
Contraceptive pill
Fish oils/plant oils/omega 3s
Ginseng/gingko biloba/St Johnʼs wort
No elements found. Consider changing the search query.
List is empty.

24.) Have you had any of the following procedures in the last 2 weeks on the area to be treated with microneedling?

None
Plastic/Cosmetic surgery
Muscle relaxant/wrinkle injections (including but not limited to Botox®, DysportTM or Xeomin®)
Dermal Fillers (including but not limited to Juvederm®, Restylane®, Belotero®, Captique® Esthelis®, Radiesse®, Aquamid®, Sculptra® or Artefill®)
Microdermabrasion
Chemical peel (including but not limited to glycolicacid, lactic acid, mandelic acid or salicylic acid)
Derma blading/derma planing
Laser/IPL rejuvenation/hair removal
Radio Frequency (RF) skin tightening
Photo dynamic therapy (PDT)
Dermabrasion
Deep chemical peel
Tattooing/cosmetic tattooing
Electrolysis/diathermy
Hair removal (including but not limited to waxing, sugaring, plucking, threading or depilatory cream)
Spray/self-tanning
No elements found. Consider changing the search query.
List is empty.

25.) Patient signature

Clear

26.) Patient signature date

27.) Practitioner signature

Clear

28.) Practitioner signature date

Website

LASH & BROW ENHANCEMENT

These may include but are not limited to:

A. Allergic reactions to products used during the treatment.

B. Skin irritation, redness, or swelling.

C. Infection if proper aftercare instructions are not followed.

Microneedling Consultation & Consent Form

Emergency Contact Information

Medical History

These may include but are not limited to:

A. Allergic reactions to products used during the treatment.

B. Skin irritation, redness, or swelling.

C. Infection if proper aftercare instructions are not followed.

Microneedling Consultation & Consent Form

Emergency Contact Information

Medical History

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