Client Consultation Form
Unit 869 – Apply Prosthetic Pieces and Bald Caps
College Name:
College Number:
Learner Name:
Learner Number:
Date:
PERSONAL DETAILS
Age group: Under 20
20–30
Lifestyle: Active Sedentary
Last visit to the doctor:
GP Address:
No. of children (if applicable):
Date of last period (if applicable):
Client Name:
Address:
Profession:
Tel. No: Day
Eve
30–40
40–50
50–60
60+
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical
permission cannot be obtained clients must give their informed consent in writing prior to treatment
(select if/where appropriate):
Nervous/Psychotic conditions
When taking prescribed medication
Epilepsy
Skin cancer
Recent facial surgery affecting the area
Undiagnosed pain in the face
Diabetes
Slipped disc
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Allergies
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or
alcohol
Diarrhoea and vomiting
Any known allergies
Eczema
Undiagnosed lumps and bumps
Localised swelling
Inflammation
Cuts
Bruises
Abrasions
Scar tissue (2 years for major operation and 6
months for a small scar)
Sunburn
Hormonal implants
Urticaria
Recent fractures (minimum 3 months)
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(select if/where appropriate):
Sinusitis
Neuralgia
Sunburn
Migraine/Headache
Hypersensitive skin
Botox/dermal fillers (1 week after treatment)
Hyperkeratosis
Skin allergies
Trapped/pinched nerve affecting the treatment
area
Inflamed nerve
Conjunctivitis
Any eye surgery (approximately 6 months)
Styes
Hay fever
Watery eye
Blepharitis
Psoriasis
SKIN ANALYSIS:
SKIN SENSITIVITY/PATCH TEST
(Documentary evidence of patch test to be included):
Product tested:
Positive
Negative
REASERCH MATERIALS:
DESIGN DETAILS/SPECIFICATION: (Clear explanation and instructions of how to create the
look):
SKIN PREPARATION PRIOR TO PROSTHETIC APPLICATION: (Clear explanation and
instructions)
BALD CAP T-PIN REMOVAL:
COLOUR CORRECTION AND MAKE-UP APPLICATION:
REMOVAL AND CLEANING:
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Unit 869 – Apply Prosthetic Pieces and Bald Caps
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Treatment to include (select if/where appropriate)
Character Design
Preparation of tools and equipment
Cleanse and skin analysis
Skin Preparation and prosthetic application
Colour Corrector
Prosthetic pieces (nose/ears/chin) delete where appropriate
Bald Cap (Rubber/Silicon/Gelatine/Vinyl) delete where appropriate
Adhesive
Adhesive remover
Airbrush//Rubber Mask Make-up (delete where appropriate)
Brushes
Palette Tray
Acetone
Modelling tool
Couch roll
Marker Pen
Scissors
Powder puff
Powder
Bald Cap Block
Tissues
Q-tips
Completed Face-Chart
Additional Make-up Products
Brush Cleaner
Bald Cap T-Pin Removal
Photo’s
PHOTOGRAPHS:
(Showing progressive shots)
Client feedback: (if applicable)
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Aftercare advice: (including details on prosthetic/make-up removal):
Client’s Signature...........................….....................................
Learner’s Signature.........……………………...........................
Skin Sensitivity/Patch Test
Client Information
Please read carefully and only sign if you are in full agreement with its contents
I ------------------------------------------- confirm that I have received the required patch test (s) 24-48 hours
prior to receiving fashion and photographic make-up treatment and confirm that I am willing to
proceed.
You should note that if the Learner is unable to explain to you the treatment contra-actions and
contraindications or is unsure of anything that may apply to a specific condition then they should not
treat you without asking you to consult with your GP or Consultant.
It is your responsibility and not that of the Learner to consult your GP or Consultant.
I hereby indemnify the Learner against any adverse reaction sustained as a result of the treatment
Client’s Signature........................................
Date..........................
Learner’s Signature.....................................
Date...........................
Unit 869 – Apply Prosthetic Pieces and Bald Caps
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