HARMONY MEDICAL FORM

AMALASER LTD

353 Lordship Lane, London SE22 8JJ

Email: info@amalaserclinic.com

www.amalaserclinic.com/

+(44) 7563 884934
MICROBLADING CONSULTATION & CONSENT FORM
PERSONAL INFORMATION
Gender*
Date of Birth*

MonthDayYear
Full Name*

First NameLast Name
Mobile or Landline*
E-mail
example@example.com
How did you hear about us?*
Please Specify
MEDICAL INFORMATION
Are you currently taking any medications?*
If Yes please List:
Do You have any allergies?*
If Yes please List:
Skin Contraindications: Do any of the following apply to you? Please tick all that apply.

Ingrown hairs and open bumps on eyebrowsEczemaPsoriasisDermatitisRosaceaMoles/raised areas on/around eyebrowsDeep wrinkles in the eyebrow areaFitzpatrick Skin Type 1Use of Accutane within the last yearUse of Retinol or Vitamin A within the last yearExtremely thin skinTunned/Sunburnt skinUse of eyelash/eyebrow growth serum within the last 2 monthsFace/Body dysmorphic disorderHypo-pigmentHyper-pigment
Medical Contraindication: Do any of the following apply to you? Please tick all that apply.

HepophilliaHeart ConditionPacemakerDefibrillatorUse of blood-thinning medication
Treatment Name*
Treatment Date*

MonthDayYear
Date
Emergency Contact Name *

First NameLast Name
Emergency Contact Phone*
Emergency Contact Relationship

HusbandWifePartnerMotherFatherFriendOther RelativeOther
Consent

Please read carefully.

● I understand that the service is part of a training session which means it may take longer than a regular
appointment and I can commit to the full timings.
● I understand that the service may be carried out by an unqualified member of staff as part of their
training, and they will be closely supervised by a senior, qualified member of staff at all times.
● I accept that any service I receive as a model is at my own risk.
● I understand that failure to disclose the information requested above may result in adverse side effects from
the treatment(s) received and therefore I accept full liability/responsibility for the information given.
● The treatment(s) and possible side effects have been fully explained to me.
● I accept full responsibility for the treatment given and complications which may arise, or result during, or
following any procedure that is performed at my request.
● I fully understand the above and consent to receive treatment as part of a training session.
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MICROBLADING CONSULTATION & CONSENT FORM

PERSONAL INFORMATION

MEDICAL INFORMATION