CLIENT INTAKE FORM
Name
*
First Name
Last Name
Cell Number
*
Email
*
example@example.com
Service Name
*
MEDICAL INFORMATION & HISTORY
Do you have body tattoos?
*
yes
no
Do you have previous permanent makeup?
*
yes
no
Do you have allergies (ie, Latex Gloves?)
*
yes
no
Are you allergic to anesthetics?
*
yes
no
Are you allergic to antibiotics?
*
yes
no
Have you recently had eye surgery?
*
yes
no
Are you currently pregnant or breastfeeding?
*
yes
no
Do you have any history of Keloid scarring?
*
yes
no
Do you have Rosacea or Eczema?
*
yes
no
Do you suffer from Thyroid condition?
*
yes
no
Are you diabetic?
*
yes
no
Do you have any skin conditions?
*
yes
no
Have you ever been on 'Accutane'?
*
yes
no
Do you get Herpes (Cold sores)?
*
yes
no
Have you ever tested positive to HIV or Hepatitis?
*
yes
no
Are you currently taking medication, including immunosuppressants such as anti-inflammatory or steroid?
*
yes
no
Do you use Retinol, Proactive or any other anti-aging products?
*
yes
no
Are you able to take antihistamine (Tylenol) over the counter?
*
yes
no
Do you have any medical conditions? Please specify.
*
WAIVER, RELEASE & CONSENT FORM
Please write your initials if you agree to the statement
I am over the age 18 and I am not under the influence of drugs or alcohol. I am not pregnant or nursing
I have been candid in revealing any condition in my 'Client Intake Form' that could prohibit or alter my treatment such as, but not limited to recent surgeries, sun exposure/tanning, tendency of scaring, Accutane in the past 24 months
I accept responsibility for determining the color and the shape of the brows/lips as agreed to during the consultation. I fully accept that non toxic pigments are used during the procedure and that the results achieved may fade over a period of 1 3 years depending on skin type & lifestyle
I understand that pigment can remain in the skin indefinitely
I understand that results of my treatment are affected by the following: medications, skin characteristics (dry, oily skin etc.) pH balance of skin, lifestyle (tanning, sun exposure, exfoliating, daily skin routines) and aftercare
Upon completion of the treatment I understand my skin might be slightly red, irritated of swollen
To my knowledge, I do not have physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time
I agree to follow the post procedure instructions as provided and explained to me by my artist
I followed my pre appointment instructions that were provided to me by my artist
If I am unhappy or unsatisfied with my appointment, I will not slander Viktoria Bromberg in any online forum including Google, Yelp, Instagram, Tiktok, Facebook groups, and Twitter. I will contact Viktoria Bromberg to allow her to work with me to find a reasonable solution
I fully understand that this is a tattoo process and therefore not exact science but an art. I understand that every effort will be made to avoid asymmetry but our faces are not naturally symmetrical and Alpha Glam Services will advise only on natural permanent makeup services
I hereby consent to, and authorized the use of photography and video; photos are taken during the procedure and can be used on the Artists portfolio page. I understand that I am not entitled to compensation for these photos being used
I have been advised that the true color of the pigment will be seen 1 month after each procedure and that the pigment may vary according to skin tone, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee is made by the artist
Client Signature
*
Date
*
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Month
/
Day
Year
Date
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