Ombre Powder Brow Consent Form

Ombre Powder Brow: Medical History and Consent Form

Please take a moment to answer this form as accurately as possible to communicate all past and existing medical conditions and provide consent for your service.
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email
example@example.com
What is your skin type?*

DryNormalOilyCombination
Do you have any blood borne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis (A,B,C,D) ?*

YesNo
Are you currently pregnant or breastfeeding? If yes, you must not be pregnant or nursing at the time of appointment.*

YesNo
Have you had Botox within the past 6 months in the brow/forehead area?*

YesNo
Have you had any surgeries including blepharoplasty (eyelid surgery) and/or forehead/brow lift?*

YesNo
Allergies to any medications such as Lidocaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.?*

YesNo
Are you currently on any blood-thinning prescription drugs?*

YesNo
Please check all that applies to you:

Abnormal Heart ConditionHemophiliaHigh Blood PressureCirculatory ProblemsEpilepsyThyroid DisturbancesCancerSeizuresAlopeciaWatery EyesKeloid ScarsAnemiaLow Blood PressureDiabetesSuffer from Eye InfectionsAutoimmune ConditionsOther TattoosBruise of Bleed EasilyAllergy to Latex/Metals/ AntibioticsAccutane/Prescription Acne Medicine within last 12 monthsEczema (face)Psoriasis (face)HerpesSensitivity to CosmeticsNone of the above
Please upload bright photos of your bare brows in various angles below. Up to 5 photos.

Cancelof
Special requests, concerns or remarks for technician:
Please note that this procedure can have certain side effects such as redness, swelling, tenderness, soreness, etc. I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the ombre powder brow procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: avoiding excessive sun exposure, sweating, tanning, saunas, swimming pools, and certain facial treatments; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
Date

MonthDayYear
Date
Signature
Should be Empty:

Ombre Powder Brow: Medical History and Consent Form