Lash & Brow Exclusive
Online Cosmetic Tattoo Consult
Full Name
*
First Name
Last Name
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*
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Phone Number
*
mobile phone number
Address
*
Street Address
Street Address Line 2
City
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Postal / Zip Code
Email
*
example@example.com
Due to new regulations for compounded numbing creams Lash & Brow Exclusive can not purchase or supply numbing cream on your behalf. We work with a pharmacist who will complete you're numbing cream order and post the creams to the salon. We can then assist you in applying the cream when you arrive to your appointment.
*
I understand and accept to comply with the pharmacy regulations
Anaesthetics - The topical anaesthetics used contain Lignocaine, Tetracaine and Epinephrine. Do you give your permission for these creams to be used on you before and during your procedure?
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Yes I give permission
No
Have you ever used topical anaesthetics (numbing cream) on your face or body?
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Yes - and I had no reactions or irritations
Yes - but I had a reaction or irritation
No
Other
Check the conditions that apply to you:
*
Diabetes
Cancer current
Chemotherapy or radiation in the last 12 months
Heart conditions
Taking blood thinning medications
Epilepsy
Addisons Disease
HIV
Hepatitis
Hemophilia
Low blood pressure
High blood pressure
Type 1 Diabetes
Auto Immune disorder
Thyroid disorder
Stroke
Bells Palsy
Scleroderma
Skin disorder
Prone to keloid scaring
Eczema or Psoriasis on the face
Tumors, growths or cysts
Vitiligo
Melasma
Recent surgery
Trichotillomania
Conjunctivitis currently
Fainting or dizzy spells
Coldsores
Breast feeding currently
Pregnant currently
Problems with healing
Alleriges to metals
Allergies to skin care ingredients
Reaction to Vaseline/petroleum base
Using Retin-A/Vit A, prescribed skin care, Accutane
Had Botox or Filler in the past 3 weeks
Body Dysmorphia
Depression currently
Anxiety
Currently taking Antibiotics
Other medical condition not listed
Taking Acne medication in the last 12 months or currently
Alcohol in the last 7 days
None of the above
Do you have any known allergies?
*
Yes
No
If yes to allergies list here
Are you currently taking any medications or supplements?
*
Yes
No
If you are taking medications or supplements please list them here
please list all medications or supplements
Do you have any previous lip or brow tattoo done elsewhere?
*
Yes - fill out below
No
If Yes how old is the tattoo and who did it?
Are you over 18 years old?
*
Yes
No
What is your skin type?
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Normal
Normal/Dry
Oily
Sensitive
Combination Oily
Oily with Acne
Is your skin:
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Thick with enlarged pores
Thin with visible veins
Sundamaged
Dry flaky skin in the eyebrows
None of the above
Please select any lifestyle factors relevant to you
*
Outdoors often
Exercise regularly
Swimming often
Smoker
In steamy hot environments often
None of the above
What are your main concerns with your brows or lips?
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Brows too thin
Brows have bald patches
I want a better shape
I can't draw them on
Lips are patchy
Lip line is not defined
Other
Which Cosmetic Tattoo procedure do you wish to have done?
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Microblading Brows
Ombre Brow Shading
The Burleigh Brow
Lip Blush Tattoo
Not sure
I understand that this treatment is for cosmetic enhancement purposes only and that no guarantees have been made to me regarding the results including fading, some people hold pigment colour better than others for reasons out of our control so no exact timeframe of colour last is given.
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Yes
No
I am responsible for the 'at home after care' post procedure which may have risk of infection or premature fading of colour pigment if the after care is not followed properly. Your hands must be washed before coming in contact with the tattoo throughout the entire healing process. It is extremely important to follow all after care for the instructed timeframe.
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Yes I agree to follow the after care
No I can't follow the after care
I am aware I have the opportunity to ask questions relating to this treatment prior to, and during the procedure if there is anything I do not understand or know
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Yes
No
I am aware I will need to return for the 6 week touch up treatment to finalise the procedure and get the final result. In SOME cases (after care not followed, oily skin type, medical conditions, lifestyle, very light colour choices or request of very light coverage of tattoo), an additional touch up appointment may be necessary to attain optimum results - this is charged at an additional fee of $150 and must be done 6-12 weeks post the touch up appointment.
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Yes I agree and understand
No I do not agree or understand
I understand I must wait at least 4-6 weeks for healed results to be seen. At the 4-6 week touch up appointment any colour changes, shape alterations or other adjustments will be done then and NO SOONER due to risk of scarring.
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I understand and agree
No
I understand that allergic reactions can occur at any point in my life to anything and that allergies can develop over the duration of time, even if an initial exposure didn't cause a reaction. Because of this I understand and accept that allergic reactions are possible to this treatment and I cannot hold Lash & Brow Exclusive responsible or try to claim from Lash & Brow Exclusive for cost of medical expenses in the event a reaction should occur
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Yes I agree and understand
No I do not agree
Should a allergic reaction occur I will seek the advise of my medical practitioner and inform Lash & Brow Exclusive of the reaction and outcome.
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Yes
No
I understand application of cosmetic tattooing can be uncomfortable.
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Yes I understand
No
I am aware that I cannot give blood for 4 months post the touch up treatment (this is a universal tattoo law)
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Yes
No
Why do you want to have cosmetic tattooing?
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example: to get a more modern shape
How long have you been considering Cosmetic Tattooing?
*
When are you wanting to have the procedure done?
*
Do you have any special occasions coming up, such as a wedding or holiday?
*
Have you discussed the procedure with family/spouse/friends and are they happy for you to have cosmetic tattooing?
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Yes
No
Not relevant - im happy to make the decision for myself
I accept full responsibility for the shape, colour and position of the cosmetic tattoo as per the 'pre treatment design' that will be drawn on prior to commencing the procedure. I understand I have the option to ask for any changes to be made to this pre design until I'm confident and happy to go ahead.
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Yes I accept and understand
No
I will be shown that all equipment used for my procedure is new and sterile tools will be used for every treatment.
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Yes I understand
No
I have read and understood all questions and information on this form and have answered truthfully
*
Yes
No
I understand no refunds are given under any circumstances
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Yes I understand
No
I agree to for the purpose of documentation, consent to the taking of before, during and after photographs of the prodcedure for record purposes and for the use on social media
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Yes to all of the above
No
Yes but not for use on social media. For records only
Please upload a close, CLEAR front on photo of your brows or lips with your eyes open. (please ensure there is lots of good lighting) and upload here. BELOW IS AN EXAMPLE
*
UPLOAD BROW OR LIP SELFIE
Upload your brow or lip selfie
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