Eye treatment consultation form.

Please complete this consultation form before your appointment so we can provide you with the safest and most effective treatment. The information helps us understand your health history and tailor the service to your individual needs.

Client details

Client name Client phone number Email

Health history

Do you have any eye conditions? Yes No

Have you had any recent eye infections or irritation? Yes No

Are you allergic to latex, adhesives, tint, or beauty products? Yes No

Did you experience any reaction to previous eye treatments? Yes No

Are you currently pregnant or breastfeeding? Yes No

Are you taking any medications that may affect your skin or eyes? Yes No

Do you have sensitive skin around the eye area? Yes No

Do you wear contact lenses? Yes No

Have you had any recent eye surgery or medical procedures? Yes No

Have you had a patch test done previously? Yes No

Have you had tinting done previously? Yes No

Have you had lash extensions done previously? Yes No

Conditions

Do you currently suffer from any of the following conditions?

Diabetes Cancer Skin condition Asthma Epilepsy Blood condition or clotting disorder No condition

Consent and disclaimer

I confirm that the information I have provided on this consultation form is true, accurate, and complete to the best of my knowledge.

I understand that withholding relevant medical or health information may increase the risk of adverse reactions, and I accept responsibility for any consequences arising from incomplete or inaccurate disclosure.

I acknowledge that all aesthetic and beauty treatments carry potential risks, including redness, swelling, irritation, allergic reaction, sensitivity, or other unforeseen side effects.

I agree to follow all pre-treatment and aftercare instructions provided and understand that failure to do so may affect results and increase the risk of complications.

I have read, understood, and agreed to the above terms and consent to proceed with my treatment.

Consent date Client signature

150 Gloucester Ave, Chelmsford, CM2 9LG

Glow.chelmsford@gmail.com

075 1112 9990

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Monday to Saturday: 10:00 AM to 6:00 PM

Sunday: Closed

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