Eyebrow Enhancement

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Let us do this part

Today's Date:

Wed Mar 12 2025 03:49

Practitioner:*

Treatment Type:*

Location on body:*

Treatment Price:*

The Cosmetic Ink Clinic
72 High Street
Milton Regis
Sittingbourne
KENT
ME10 2AN

Please read and answer

Do you have Flu like symptoms?*

IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.

Eaten?*

Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.

Have you recently/currently experienced (select all that apply);

Inflammation of Eyelid/Eyebrow Area Eye Infections/Conjunctivitis Skin Trauma, Swelling or Abrasions Eye, Head or Face Surgery. Sunburn Recent Tattoo, Microblading, Permanent Makeup Hypersensitive Skin Previous Reaction to Henna/Tint/Lamination Application Previous Botox/Dermal Fillers Chemotherapy Treatment (Current) Skin Disorders/Disease Eczema/Psoriasis

More Details*

Other Medical Conditions? If yes please give details (type N/A if nothing applies).

Are you Pregnant?*

The immune response may be affected by pregnancy; any infection may affect an unborn child

Are you currently Nursing?*

Nursing mothers treatment may interfere with the feeding process; also, any risk of infection is also a potential risk for baby.

Any other allergies?

If yes please give details

Alcohol and Drugs*

Treatment cannot be undertaken if a client is under the influence of drugs or alcohol.

Please tick to confirm you understand and agree*

I consent to a patch test. I understand that I may have an allergic reaction to products used within 24 hours and that if I do, I will not be able to proceed with the treatment.

I understand that if no allergic reaction is evident within 24 hours that it is not construed that I may not have a reaction at a later date (secondary reaction). I affirm that I will release the technician from any liability for an allergic reaction should I wish to proceed with the treatment.

I understand the content of this form and take full responsibility for my actions, thus absolving all other parties their responsibilities if any, associated with the supply of the products and services

I confirm I have read the “GDPR- How ‘The Cosmetic Ink Clinic’ collect, use and store data’ statement and give my permission for collection, handling and storage of my personal data for treatment and appointment purposes in accordance with GDPR guidelines.

Images for Marketing

I agree for my pictures to be used for advertising purposes. I understand my name and details will not be published

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Legal Name:*

Pronoun:

Chosen name:

Address:*

Postcode:*

Date of birth:*

You must be 18 or older

Gender:

Phone #:*

Email:

Signature:*

Sign above or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:

Photo ID

Please take photo(s) of your government issued photo IDs and related paperwork.