N L Fiche cliente ANGLAIS .pdf

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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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