49 High Street NF 20/21 Arndale Market Manchester M4 3AH
lilybrowbar@hotmail.co.uk
Open: Mon-Sat: 09.30 - 6.30 - Sunday 11:30 to 5:30
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Form
Client Eyelash Consent Form
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Facial Treatment Consultation Form
Patch Test / Allergy Patch Test Form
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Lily Brow Bar Consultation Form
Client Consultation Form
Aeshthetic Consultation Form
Contact
1618 345 033
Aesthetic Consultation Form
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Aesthetic Consultation Form
Aesthetic Consultation Form
Date
Client Name
Tel. No.
Email
Treatment Being Received
Have you received this treatment before yes / no? if yes did the treatment meet your needs and expections?
What are your main reasons for have the treatment with us today?
Enhance Lips
Soften Nasal Folds
Soften Marionette Lines
Soften Wrinkles
Reduce Fine Lines
Enhance Cheeks
Enahance Jaw Line
Rebalance Nose
Rebalance Chin
Improve Skin Colour
Redux Dark Eye Area
Reduce Dark Pigmentation
Improve Skin Colour
Lift Contours
Reduce Lose Skin
Improve Skin Condition
Improve Neck Area
Fat Reduction
Cellulite reduction
Improve Body Firmness
Other
What is your main facial/body concerns?
Cellulite
Lose Skin
Dry Skin
Oily Skin
Body Weight
Poor Texture
Skin Aging
Fine Lines
Wrinkles
Pigmentation Scaring
Dropped Contours
Skin Infection
Fat Pockets
Skin Colour
Veins
Blocked Pores
Dehydration
Poor Radiance
Water Retantion
Other
What treatment are you currently doing to improve your main concern?
Describe your tolerance to needles?
-- Select --
Low
Medium
High
If you have selected a low tolerance, please explain more about any fear you may have?
Do you have a known allergy to topical anaesthetic/lidocaine ?
-- Select --
Yes
No
Please answer yes or no to the following statements and sign below
I give my permission for the practitioner to administer topical anaesthetic/lidocaine to the area being treated on my body
-- Select --
Yes
No
Aesthetic treatments are classed as invasive. I understand I may experience one or more of the following normal sensations during treatment-Discomfort Tingling Watery Eyes/ Sharp Pain/ Numbness/ Heat
-- Select --
Yes
No
Aesthetic treatments are classed as invasive. Due to this I understand I may experience one or more of the following normal contra-actions after treatment- Bruising/Swelling/ Discomfort
-- Select --
Yes
No
I understand that bruising can last up to 2 weeks post treatment
-- Select --
Yes
No
I understand there are no guarantees as to the success or longevity of my treatment
-- Select --
Yes
No
I understand that results are only temporary, and my practitioner has explained the expected time frame
-- Select --
Yes
No
I understand my condition or medication may affect the treatment including bruising, bleeding and additional healing time
-- Select --
Yes
No
I understand that my practitioner is required to take photographs of the treatment areas before and after every procedure and agree to this being done
-- Select --
Yes
No
My technician has discussed likely outcomes with me and recommended a treatment plan
-- Select --
Yes
No
I understand that my practitioner is required to take photographs of the treatment areas before and after every procedure and agree to this being done
-- Select --
Yes
No
My technician has discussed likely outcomes with me and recommended a treatment plan
-- Select --
Yes
No
I have been given aftercare instructions and understand that I must stick to these instructionsment plan
-- Select --
Yes
No
Client Name
Date
Do You have any concerns or additional questions?
Before submitting the form, please check in with the shop staff. Otherwise, you will need to refill the form.
Send Message
Send Message
lilybrowbar@hotmail.co.uk
1618 345 033
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