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Consultation Form

First Name

Last Name

SMS Number (+61)

Date of birth

Today's Date

Address (optional)

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

Skin:

What is your skin type? dry, oily, combination or normal

Have you had face laser or skin peels in last 8 weeks?

Yes

if yes, please give details.. (optional)

Have you had any kind of cosmetic procedures? Botox, Fillers, Facelifts, Brow Threads in last 8 weeks?

Yes

if yes, then please confirm the treament and how long ago?

Have you had any previous Cosmetic Tattooing on the brow area?

Yes

if yes, please give details.

Medical History:

Are you taking any medication or supplements?

Yes

if yes, please give details.

Please indicate if you suffer from any of the following condition?

Jaundice/Hepatitis

Melasma ( Pigment changes in the face )

Diabetes

Keloids

Blood Disorders

Moles ( in the brow area )

Scar Tissue ( in the brow area )

Sun Burn ( in the brow area )

Eczema

Psoriasis

Acne

Albinism/Vitiligo

Pigment Birth Mark ( in brow area )

Cold Sores

Psychiatric illness/ Depression

HIV

Thyroid Problems

Convulsions

Bell's Palsy

Hypoglycaemia ( Low Blood Sugar )

Anxiety

Skin disorders/ Diseases

Are you currently pregnant or breastfeeding?

Yes

Do you smoke regularly?

Yes

Do you drink alcohol regularly?

Yes

Have ever had any adverse reaction to any beauty treatment including injectables or numbing agents?

Yes

if yes, please give details.. (optional)

Is there any aspect of your health that you think we should know about?

I have answered all the questions best of my understanding.. ( Sign Below)

Upload some clear photos of the area you are enquiring about ( Natural lighting, No filters or Makeup

Select Files

Additional Information ( if you answerd yes to any of the above please provide details as well as what you would like to achieve Cosmetic Tattooing )

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browsbyj@hotmail.com

0416073722

JAYNE CONTE

BROW ARTIST

Shop 15, 7 Goode Street 3437 VIC Australia

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