Returning Client | Update
Please complete prior to your scheduled appointment.
Date
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Month
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Day
Year
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Name
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First Name
Last Name
Date of Birth
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Photo release - do you give permission for The Browe Bar to potentially use photos of your treatment on social media & advertising outlets?
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Yes
No
Maybe
About Your Skin
What is your skin type?
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Normal
Combination
Dry
Oily
Sensitive
Not Sure
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Retinol, or other Vitamin A derivatives?
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Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
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Yes
No
About Your Health
Any recent changes to your health we should be made aware of?
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Yes
No
Do you have any recent head, neck, shoulder, or hand injuries?
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Yes
No
Any known allergies?
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Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Other
None
Are you a smoker?
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Yes
No
Please rate your stress level
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Low
Medium
High
FEMALE CLIENTS
Are you pregnant or trying to become pregnant?
Yes
No
Recently had a baby and am breastfeeding
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release The Browe Bar from liability and assume full responsibility thereof.
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I Agree
Signature
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