BROWS & LASHES Consultation Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number *

Please enter a valid phone number.

Date of Birth *

Date

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Please select which treatment you are having (you can select more than one option if need be):

Brow LaminationHD BrowsEyelash ExtensionEyebrow Architecture without colour

If you have any of the below recently please state yes and give additional information requested where relevant. Otherwise, enter N/A or No.

Do you have any Allergies or Sensitivities, including dietary? (List here)*

Are you currently on any medication, topical or oral, antibiotics, steroids, especially blood thinners? (List here, along with the conditions they are treating)*

Have you ever had any allergic reaction to the hair colour or henna/tint. (if yes please indicate date)*

Do you have an Autoimmune Disease? (Please identify)*

Are you pregnant or breastfeeding?*

PLEASE READ THE BELOW CONDITIONS CAREFULLY & TICK ANY THAT APPLY

	YES	NO
Cancer
Chemotherapy or Radiotherapy treatment within last 6 months
Blepharoplasty within last 6 months
Epilepsy
Haemophilia
Diabetes
Thyroid Condition
Alopecia
Blepharitis / Barley / Conjunctivitis
Anemia
Skin Conditions
Trichotillomania (hair pulling disorder
Eye disorders
Eczema in the treatment area

Do you have any other medical consultation or disease not listed above? (Please indicated here)

Any other information you would like to provide?

I understand that during subsequent visits it is my responsibility to inform the technician of any updates to the answers I have provided on this form.

Agreement Terms

I understand that during subsequent visits it is my responsibility to inform the technician of any updates to the answers I have provided on this form.
I certify that the information above is true & correct and I have not withheld any information requested on this form. I understandg that it is my responsibility to inform the technician of any medical or health conditions, as they may affect my treatment. Failure to answer truthfully may result in personal injury. My submission of this form constitutes my consent to treatment. I hereby give my consent and authorisation voluntarily. I release this establishment and its agents from liability for any injury, loss or damage that may result from any information I have withheld.
I understand that even though the highest quality products are used during my Brows and Lashes Procedure with WM Permanent Make Up, there is a risk of an allergic reaction to one or more of the ingredients of the products used during my procedure.
A patch test is required for all new clients for Brows Lamination, Tint, Henna at least 24/48 -hours prior appointment. This must be done even if you have carried out patch tests with other artists before for insurance policy purposes.
I confirm that I have had a patch test prior to my appointment with no adverse reaction.
I understand that even with a negative Patch Test result, an allergic reaction can still occur that can not be predicted, and I understand that WM Permanent Make Up can not be held liable for an allergic reaction.
I understand that my artist CAN NOT provide medical advice in the event that I do have an allergic or otherwise adverse reaction to my procedure, and I certify that I will seek qualified medical attention in the event that I experience symptoms of an allergic reaction or potential infection.
I agree to follow the Before & After Care Instructions provided perfectly in order to ensure my satisfaction with the final results and only use the after care products provided.
I understand that some irritation, itching or burning may occur to the skin which comes in contact with the henna, lamination, glue for lashes agent.
I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time.
I understand that, while every attempt will be made to provide me with my chosen colour, everyone’s hair absorbs colour differently and my final results may not be the colour I initially wanted.
I understand that over the course of several weeks, the tint will gradually lighten and fade. Re-henna will be required to keep the new colour fresh. Most clients need to re-henna every 3-4 weeks.
I understand that my technician will be taking photographs before and after the treatment for record keeping and liability purposes and that this is necessary if I am to undergo the procedure. These photos may be shared on WM Permanent Make Up social media accounts and if I wish to remain anonymous I have the right to request my identity be hidden (close-up of brows & eyes only.)

DEFINING WM Permanent Makeup FEES & POLICIES

The consultation or online consultation (through messaging, email, or WhatsApp) is offered prior to having the service. This consists of your answering relevant health-related questions to ensure it is safe for you to have the treatment done.
A deposit of Service Cost Booking Fee is required to schedule your treatment, but will be subtracted from the cost of your treatment.
If you cancel the appointment with more than 72 hours notice, your deposit will be refunded.
With less than 72 hours notice, the Booking Fee is non-refundable for cancellations, and can only be rescheduled (up to 48 hours prior).
I do understand that schedules sometimes change- if this is the case and you need to reschedule your appointment, you may do so and transfer your deposit as long as it is with a minimum of 72 hours notice. Rescheduling within less than 48 hours will result in forfeiting the booking deposit, and require a new Booking Fee of the full service price to reschedule.

**Exception clause in place under the COVID-19 Policies. The pre-screening call will allow for cancellation/rescheduling due to Covid symptoms at/before the 72 hours window, and an emergency exception for NEWLY onset COVID symptoms the day of your procedure allows you the ability to reschedule if you will provide information form your doctor.**

If you fail to notify to me not coming for yours appointment, or you arrive more than 15 minutes late for your service, you will forfeit your booking deposit, and be required to pay the service in full prior to re-booking to respect the high demand of booking requests, we want to ensure we are reserving our sought after booking slots for clients that are 110% committed to attending their appointment.

Chronic Rescheduling challenges will result in no longer being able to book future sessions. Clients may reschedule twice within the policy guidelines above before they forfeit their booking deposit.

By signing and submit this form, I am acknowledging that I have read and fully understand the policies.

I fully understand the procedure and give permission to my technician to perform the Permanent Makeup procedure I've chosen, and all of the associated procedures and steps involved. By submitting this form, I am acknowledging that I have read and fully understand the policies.*

YesNo

I consent to Wioletta Malochleb Permanent MakeUp using this information to contact me.*

YesNo

I consent to photograph, filming, recording and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose, any promotional materials and for Social Media.*

YesNo

I confirm that I HAVE NOT had any of the following symptoms in the last 10 days: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat | I DID NOT test positive in the last 10 days

YesNo

Signature*

Date*

Date