INTAKE FORM - Brow Designery

Brow Designery

Client Intake Form
1) CLIENT'S DATA
Full Name *

First Name Last Name
Mobile Number *

Area Code Mobile Number
Email *
example@example.com
Complete Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth: *
MM/DD/YYYY
Gender *
Age: *
Are you a new or returning client? *
2) ELIGIBILITY
Are you under 18 years of age? (If “yes” you are ineligible to book) *

Yes No
Are you Pregnant or Nursing? (if "yes" you are ineligible to book) *

Yes No
Are you on Accutane or were you previously on Accutane and off of the medication for less than one (1) year? (if "yes" you are ineligible to book) *

Yes No
Are you undergoing Chemotherapy or have undergone Chemotherapy and been in remission for under one(1) year? (if "yes" you are ineligible to book) *

Yes No
Are you using any Retinoid, AHA's/BHA's, or products containing Active Ingredient? (If "yes" you must stop using these products for a minimum of two weeks leading up to your appointment) *

Yes No
Do you have an existing cosmetic tattoo? (if "yes", you are able to confirm that you're eligible to book with our Artist's approval, during the online consultation. *

Yes No
By checking this box I confirm that I have acknowledged that failure to provide accurate information may results in a cancellation of my appointment and forfeit of my deposit. *

I confirm
3) COVID-19 SAFETY PROTOCOLS / POLICIES
Personal Protective Equipment must be worn in order to enter our facility and must be worn at all times during your appointment. A single-used PPE will be provided with an additional cost of PHP 350. We are limiting the use of our space to our Artists and Clients ONLY – please refrain from bringing guests as they will not be permitted within the facility.

If you are experiencing symptoms within 72 hours of your appointment please inform us IMMEDIATELY – no penalty will be issued for last minute reschedules associated with COVID19.

Due to the unpredictable nature of COVID-19 appointments may be subject to rescheduling. In the event of mandated closures deposits will not be reimbursed and a new appointment date will be provided instead.
I understand Brow Designery will require proof of full vaccination against COVID-19 before entering the studio. *

I confirm
Are you exhibiting any respiratory symptoms like coughing or shortness of breath? (if "yes" you are ineligible to receive service at this time) *

Yes No
Are you exhibiting TWO OR MORE of the following symptoms: fever, headache, loss of taste/smell, chills, muscle pain, sore throat, vomiting, or diarrhea? (if "yes" you are ineligible to receive service at this time) *

Yes No
Have you visited/worked in any healthcare setting that have confirmed COVID-19 cases within the 14 days leading up to your appointment? (if "yes" you are ineligible to receive service at this time) *

Yes No
Have you recently been exposed to anyone with a confirmed case of COVID-19? (if "yes" you are ineligible to receive service at this time) *

Yes No
I acknowledge that due to the nature of COVID-19 my appointment is tentatively confirmed and subject to further rescheduling in the event of mandatory closures or infection. *

I confirm
Upload a clear photocopy of your Vaccination Card *

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4) ADDITIONAL INFORMATION
Do you have any of the following conditions? Check the following applicable conditions. *

Hypertension Heart issues Rashes Diabetes Problems healing wounds Issues blood clotting or history of hemphelia History of keloid scarring History of cold sores or fever blisters History of anemia Spinal Cord Issues History of skin disease or skin sensitivity Epilepsy Facial moles or birthmarks None of the above
Skin Type *
How did you hear about us? *
Let's Connect! Include your IG handle below to help us reach out and answer questions: *
www.instagram.com/username
Please provide a clear photo of your BARE FACE (front facing, no filter, no makeup) as a reference upcoming appointment. *

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5) APPOINTMENT RESERVATION
Choose a procedure *

Brow Microblading Man Brows (Male Microblading) Signature Combo Brows (Microblading + Soft Shading) Powder Combo Brows (Microblading + Machine Shading) Velvet Liner Aquarelle Lip Blush Tattoo Saline Tattoo Removal 6 to 8 Weeks Touch-Up Appointment - Brow PMU 6 to 8 Weeks Touch-Up Appointment - Lip Blush 6 to 8 Weeks Touch-Up Appointment - Velvet Liner Studio Appointment Consultation Designer Lash Lift Annual (Yearly) Touch Up
Choose a Schedule:
Your prefered mode of payment for the 20% reservation deposit (non-refundable) ? *

GCash BPI Online Deposit BDO Online Deposit
6) TERMS CONDITION
- I confirm that all information given in this form is true, complete, and accurate.
- I am over 18 years old and can provide a valid ID.
- I am not pregnant or nursing.
- I do not have any history of herpes infection, diabetes, cardiac valve disease and / or have any condition mentioned in the list of health contradictions.
- I acknowledge that I voluntarily elected to obtain a micropigmentation or cosmetic tattoo procedure, and I consent to the procedure and to its related risks, and to any actions or conduct of The Artist reasonably necessary to perform the procedure.
- If I have had previous work done, I have already sent a photo and filled up a Consultation Form with the Artist's approval before booking an appointment. Failure to disclose this information may lead to the cancellation of my appointment.
- I do not have any keloids, and am not prone to keloid scarring.
- I agree that Brow Designery™ reserves the right to refuse or cancel any service to anyone who fails to follow our Booking Policy.
- I agree to settle the 20% online booking fee within the 12 hours after filling out the intake form and my appointment will be confirmed once I have received an appointment confirmation through email.
- The 20% online booking fee is NON-REFUNDABLE under any circumstances and is due to secure your date, time, and turn away other clients. The remaining Balance Payment will be due at the date and time of your scheduled appointment.
- If you book an appointment and failed to disclose your previous work without prior consultation then you may get turned away and forfeit your downpayment deposit fee.
I have read the Booking Policy and agree to the Terms and Conditions. I agree by booking an appointment online, my 20% downpayment cannot be refunded under any circumstances.

I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Date Signed *

Month Day Year
Date
Signature of the Client *

Clear
Should be Empty:

Brow Designery

1) CLIENT'S DATA

2) ELIGIBILITY

3) COVID-19 SAFETY PROTOCOLS / POLICIES

4) ADDITIONAL INFORMATION

5) APPOINTMENT RESERVATION

6) TERMS CONDITION