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PMU · LIP BLUSH · CLIENT CONFIDENTIAL RECORD

Your consultation,
at your own pace.

Client consultation & consent form

Complete your details and medical history, then review the consent statements. Only acknowledge discussions or aftercare once they have actually taken place. You can save a draft in this browser at any time. Bella completes the practitioner sections with you at the appointment.

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Checking for a matching completed full form requires your booking and contact details.

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Client details

1. Medical history

Please select YES or NO for every question. Provide details for any YES answer.

2. Lip & treatment history

3. Contraindications & suitability

7. Client consultation

8. Understanding of the treatment

    9. Risks & possible side effects

    10. Cold sore acknowledgement

    I understand that lip blush can potentially trigger a cold sore outbreak in individuals who carry herpes simplex virus. The practitioner cannot prescribe medication unless legally qualified and authorised to do so.

    11. Aftercare acknowledgement

    Leave this blank and save a draft if you have not received the aftercare instructions yet.

    12. Photography & record keeping

    Marketing consent is optional and refusing consent will not affect treatment. Select No if you do not wish to consent.

    13. Client declaration & consent

    Client signature

    Draw with your mouse or finger, or use the typed signature option.

    Client notes

    Save your form

    Check your answers before signing. Submitting this form sends your booking request for Lilly’s approval. Bella must still review your information and confirm treatment suitability before proceeding.

    BYBELLA · SISTERHAUS, WIGAN

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