Client Information
Please Review and Complete the Following:
Full Name:
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First Name
Last Name
Date of Birth / Must be Over the Age of 18:
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Month
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Day
Year
Date
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
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Area Code
Phone Number
E-mail:
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example@example.com
Where did you hear about ChevelonBB? If someone referred you, please enter their name:
Employer:
Emergency Contact:
Name
Contact Number
1
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Client Medical History (Please check all boxes that apply):
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?
Difficulty numbing with dental work
Facial Tumors/ Growth/ Cysts
Tan by booth or salon
Chemotherapy/ Radiation
Accutane or acne treatment
Oily Skin
Autoimmune disorder
Brow/Lash Tinting
Pregnant now – Breastfeeding now
Take medication before dental work
Abnormal Heart Condition
Drink caffeine daily
Take blood thinners
Alcoholism
Facelift
Bleed Easily
Forehead/Brow Lift
Hepatitis A B C D
Diabetes
History of MRSA
I have been vaccinated at least more than 2 weeks ago.
Threads
Botox
Facial Fillers
Vitiligo
Do you have any medical conditions, diseases, or disorders not listed above? If so please type below:
Please list any medications ( OTC or prescription) you are taking. Please type below:
Allergic reaction to latex, metals, hair dye, food, or any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc. Please type below:
If you have had Cancer, please type in year:
If you have had a Chemical Peel, please type in last treatment date:
If you have had Botox or Threads, please type in last treatment date:
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Pigment Lightening Procedure Consent (Please Check ALL Boxes):
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I understand the Pigment Lightening procedure cannot be performed to pregnant women or nursing mothers.
I understand there is no way for Chevelon Brow Bar to advise on how many Pigment Lightening sessions you will need.
I understand that infections can occur if aftercare instructions are not followed correctly.
I understand there may be swelling and redness following the procedure. I may experience minor bleeding during the procedure.
I understand that scarring is extremely rare, but may occur.
I understand that the pigments will fade, depending upon my skin cycle.
I understand that after my session the treated area may appear darker, then fade over the healing time.
I will wait a minimum of 8 weeks before having my next lightening session.
I agree to release and forever discharge and hold harmless the Artist, Chevelon Brow Bar, and all employees from any and all claims, damages or legal actions arising from or connected in any way with my procedure and conduct used in my permanent makeup.
I give consent to be contacted via SMS text messages by Chevelon Brow Bar during business hours regarding but not limited to: important after care information, special deals, and promotions.
I understand the taking of before and after photographs and/or videos of my procedure are required. I give my consent and release to Chevelon Brow Bar to use any photo and/or video of myself for marketing, insurance, and future touch-up purposes.
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about my procedure and that all of my questions have been answered to my full satisfaction.
Please upload a current photo of your brows without makeup on them. Be sure to use natural lighting; this is best in front of a window or outside
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Pigment Lightening Procedure Aftercare Form (Please Check ALL Boxes):
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I understand that lifestyle, medications, smoking, metabolism, facial surgery, other procedures, and age of skin can all contribute to my procedure. Though rare, infection is also possible.
I will avoid sweating such as from vigorous exercise for at least one week post-procedure.
I will avoid exposing the area to excessive moisture or humidity, such as: facials, swimming, whirlpools (hot tubs), saunas, chlorine spas and pools, steam rooms, and steamy showers.
I will avoid tanning beds, sun, yard work, harsh soap, peroxide, Neosporin and chemicals (including skin cleansers, makeup removers, alpha hydroxyl creams, and even tooth whitening toothpaste), near the treated area until healed.
I will avoid Retin-A, moisturizers, glycolic acids, exfoliants and anti-aging products at all times (not just during healing).
If I see signs of infection such as persistent increased redness or swelling, fever, drainage, or oozing, I will contact my medical doctor immediately.
I understand temporary side effects from my procedure include but are not limited to: redness, swelling, puffiness, bruising, dry patches and tenderness. I may apply ice packs as necessary to prevent or reduce swelling, but will Not get the area wet.
I will NOT schedule a touch up session within the 8 week required healing time.
I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS ABOVE CAN RESULT IN ADVERSE EFFECTS FOR WHICH MY TECHNICIAN IS NOT LIABLE.
By my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.
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