New Page | MK WELLNESS

First name

Last name

Email

Phone

I agree to be contacted by phone or email.

Please tick any of the condtions you have:

Abdominal/ Digestive problems

Allergies

Arthritis

Asthma or lung conditions

Blood clots

Cancer / Tumors

Chronic Fatigue

Chronic pain

Depression

Diabetes

Fatigue

Fibromyalgia

Headaches or migraines

Hearing problems

Heart, circulatory problems

Hernias

High / Low blood pressure

Infectious disease

Lymph node removal

Motor vehicle accident / trauma

Muscle or joint pain

Muscle, bone injuries

Numbness or tingling

Phlebitis

Pregnancy

Rash, athletes foot/tinea

Seizures

Skin disorders

Stroke

Varicose veins

Vision problems/contact lenses

Other

None

Pigmented lesions

Recent cosmetic injectable treatments

Recent IPL or Laser

Post- surgery wound healing

Open skin

Undiagnosed lumps

Other conditions not listed above:

Have you had your brows or lashes tinted or lifted before?

Have you ever had eyelash extension before?

If no, we would like to have a patch test which we highly recommend? (note that a patch test does not guarantee that an adverse reaction will never happen) (Type Yes or No)

If yes, where have you had them applied and what brand was used?

What is your brow style?

Bold , defined, dark

Natural brown tones , gentle shape

Unsure I want to ask your opinion

Have you ever used hair colour before?

Yes

No

Have you ever had an allergic reaction to hair colour or previous tinting/lash glue/ lash lifting treatments?

Are you on any over-the counter prescription skin care? If yes please list them.

Do you wear contact lenses?

Yes

No

Do you have diabetes, lupus or any auto-immune disease? If yes please describe.

Please list any conditions you are currently being treated for by your doctor.

Please list any medications you are currently taking.

Please list any allergies.

Please note the potential risks to tinting and lash lifting:

I agree to for the therapist to use Heidi Help - a note transcribing AI.

I agree to the terms & conditions and give consent for my treatment.

I understand the potiential risks and adverse reactions of the lash and brow treatment.

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