N L Fiche cliente ANGLAIS .pdf
Nom original: N-L Fiche cliente - ANGLAIS.pdf
Auteur: Nancy Lagueux
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CLIENT RECORD FORM
Date of the first visit : _________________________________
Last name : ________________________________ First name : ______________________________
Address : __________________________________________________________________________
Phone number : ________________________ Email : _____________________________________
Have you undergone any microdermabrasion or peeling treatments before?
Oui_____ Non_____
Have you had any eye problems in the last 4 weeks?
Oui_____ Non_____
Do you use any products containing AHA or retinol?
Oui_____ Non_____
Do you suffer from diabetes, hemophilia, HIV or hepatitis?
Oui_____ Non_____
Do you have any difficulties with anesthesia?
Oui_____ Non_____
Is your tetanus vaccine up to date (important in the summer)?
Oui_____ Non_____
Do you suffer from allergies?
Oui_____ Non_____
If so, please explain :
________________________________________________________________________________
________________________________________________________________________________
Do you take medication on a regular basis?
Oui_____ Non_____
If so, please explain :
________________________________________________________________________________
________________________________________________________________________________
Natural eyebrows :
Eyebrow shape :
Angled : _____
Curved : _____
Straight : _____
Eyebrow density :
Thin : _____
Normal : _____
Bushy : _____
Desired effect :
More defined : _____
Darker: _____
Thicker: _____
Services rendered:
Date
Notes
Alllergy test :
Signature
CLIENT RECORD FORM
CONSENT FORM
I, ____________________________________________________ confirm that all the information that I have
provided above is correct. I also acknowledge having been informed that the microblading treatment is carried
out under strict hygiene conditions. All the reusable material is sterilized after each care, and all the single-use
material is disposed of in containers provided for this purpose.
I have been informed that the microblading treatment may last approximately 2.5 hours. Since the pigment will
come into contact with my skin, I consent to undergoing the required allergy test.
I agree to allow my technician to intervene in case of any irritation following the treatment and to contact her
should there be any complications.
I am fully aware of the post-treatment home care instructions as well as of the maintenance recommendations,
and I agree to follow them with the utmost rigor so as to obtain the expected results.
I consent to holding neither my technician nor Myloza Ongles et Regard responsable for any post-treatment
complications caused by either my non-observance of the specific home care instructions or any reaction
following the use of pharmaceutical products that my technician or Myloza Ongles et Regard (distributor) have
not pre-authorized.
Client Signature ________________________________________
Date ________________________________
Technician Signature ____________________________________
Date ________________________________
51 Murray Street - P.O. Box 2110
New Liskeard, Ontario P0J 1P0
(705) 647-6363
Fax (705) 647-3007


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