Client Record Card

Client Record Card

Name:__________________________________________Male □ Female □ (please tick)

Address: _____________________________________________________________________

Postcode: ___________State:____________ D.O.B___________

Phone: _____________ (AH) ______________ (Mobile) _______________ (WK)

Email: ___________________________________Website: ____________________________

When is the best time (am/pm) to contact you? ____________ Ph. or Email? ______________

Referred by or how did you find us? ________________________________

What treatment are you having today? (please tick)

Teeth Whitening □

Cosmetic Tattooing □ Lash Extensions □

□ 2 x 20 min sessions

□ Eyeliner □ Lipliner/Full lips

□ Light and Natural

□ 3 x 20 min sessions

□ Beauty Spot□Brows □Other□ Thick and Full

DermaSweep Treatment □ Laser Treatment □ Stem Cell □

□ Introductory Treatment □ Test Patch □ Sparkling Vit.C

□ Full Treatment

□ Full Hair Removal Treatment □ Sparkling Phyto-Stem

□ Photo Rejuvenation Treatment

Please read carefully and answer each section

(the more we know about your health the better we can service your needs)

1. Tick any of the following allergies that apply.

□ Lanolin□ Latex gloves

□ Medical tape

□ Novocaine/Lindocaine

□ PABA□ Metals

□ Foods ________________________________

□ Other medications/drugs

□ Other allergies _________________________

2. Tick any of the following that apply.

□ Glaucoma

□ Contact lenses

□ Conjunctivitis (pink eye)

□ Cataracts

□ Dry Eyes

□ Alopecia

□ Blurred Vision □ Eye Makeup sensitivities □ Contact lenses

□ Trichotillomania (pull out eyelashes and brows compulsively)

□ Eyebrow tinting Date of last service ____________________

□ Eyelash tinting Date of last service _____________________

□ Other eye disorders/conditions _______________________

When was the last time you visited a dentist? _____________________________

□ Chapped lips □ Cold Sores/Herpes

□ Ulcers

Are you taking medication for any of the mouth /lips conditions above? _________

What type of medication are you taking? ____________________________________________

□ Collagen Injections

□ Botox

□ Other anti aging fillers

Please name the anti aging filler _____________________________(eg.fat transfer injections)

Name the area which has been filled _________________________(eg.lips, cheeks, eyes, forehead etc.)

What was the date these treatments were performed? __________________________________

3. Please tick all of the following that apply

□ Any other tattoos. Location of tattoo/s___________________Age of tattoo/s___________

Any problems__________________

□ Piercings. Where? _________________

□ Use of a tanning bed, suntan outdoors □ Are currently tanned in the area to be treated

□ Currently using Retin A or other skin thinning lotions or creams. Where? ________________

□ Currently using Glycolic acid or other AHA products

□ Had a chemical peel. When? ___________________________

□ Do you have a scar you want softened/camouflaged? Where? ___________Age of scar? __________

□ Any keloid or hypertrophic scars? Where? _________________

□ Bruise or bleed easy

□ Prolonged bleeding

□ Healing problem

□ Other active dermatological disorders □Eczema□Dermatitis□Psoriasis

□ Active Acne□Cystic Acne□Pigmentation□ Moles/warts/skin tags Where? _______

□ Sunburn in treatment area□Rosacea

□ Skin Cancers Where? ___________ Treatment? ___________

Describe: ____________________________________________________________

4. Please tick all of the following that apply

□ Do you smoke? YesNo (please circle)

□ High Blood Pressure

□ Low Blood Pressure

□ Asthma/Breathing difficulty

□ Uncontrolled Diabetes or Diabetes

□ Currently on blood thinners

□ Anxiety/Stress/Nervousness

□ Thyroid abnormalities

□ Hemophilia or other clotting disorders□ Heart palpitations/Conditions

□ Mitral valve prolapse or valve implants□ Metal parts in the body. Where?__________

□ Currently taken or have taken roaccutane in the last 6 months

□ Pregnant or trying or breast feeding a baby□ Seizures. Please describe: _______________

□ Auto immune disorders□ HIV test YesNo(please circle) Results ________□ Epilepsy

□ Hepatitis □A □B □ C

□ Blood transfusion. When? _________________

□ Cancer/Luekemia ( within the last 3 years ) Treatment? Give Details __________________

□ Recent surgeries (last 12 months) Describe:___________________________________________________

□ Future surgeryPlease describe (eg. cosmetic or other surgery)____________________

5. Please list any medications, prescription and non prescription, that you may have taken in the last 2 weeks ____________________________________________________________________

6. If under a physicians care for any condition, please describe____________________________

10. This history form has been read, understood and signed herein, and all of my questions in

regards to my treatment have been answered satisfactorily. I am over 18 years of age, and if not have presented a parental name and authorization signature below to perform the treatment. I understand and have had explained to me proper home care treatment for my procedure. I understand that these procedures may produce some swelling, redness, itching, discomfort, numbness and adverse side effects. I understand that the treatment I have chosen is for cosmetic purposes only and no guarantees have been made to me concerning the results of the procedure. I understand that the results achieved and number of treatments required will differ from person to person.

Clients Name: _________________________Practitioners Name: ______________________

Parental Signature: _____________________Parental Name: _________________________

Clients Signature: ______________________Practitioners Signature: ___________________

Date: ________________

Date: __________________

9. Sensitivity test consent form: (applicable if you are not sure on your allergies to pigment)

I _______________________________request/do not request (please circle) a sensitivity test for pigments used for Cosmetic Tattooing on (date) __________________.

I have not had any adverse reactions from the test performed on (date) ____________and release Colores Mineral Cosmetics from any liabilities related to any allergies or other reactions to applied pigments.

Date: __________ Clients signature: __________________________

8. The present shade of my teeth is ____________________________ according to the Beyond White Teeth Whitening Shade Guide. I understand that my teeth will reach their full potential after a series of treatments depending on my original shade. I understand that I must use the Beyond White Teeth Whitening toothpaste to keep my teeth at their best between treatments and on a regular basis.

Date: __________ Clients signature: __________________________

7. I ________________________request a test sensitivity test for Softlight Laser Hair Removal on area/s _____________. I understand that this test patch will determine the overall after effects to my skin with the treatment, but not the overall results that may be achieved with full treatment.

Date: __________ Clients signature: __________________________

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