Returning Client | Update
Please complete prior to your scheduled appointment.
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Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Photo release - do you give permission for The Browe Bar to potentially use photos of your treatment on social media & advertising outlets?
About Your Skin
What is your skin type?
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Retinol, or other Vitamin A derivatives?
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
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?
About Your Health
Any recent changes to your health we should be made aware of?
Do you have any recent head, neck, shoulder, or hand injuries?
Any known allergies?
Are you a smoker?
Please rate your stress level
Are you pregnant or trying to become pregnant?
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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