Essence Skin Bar Brow Consultation Form
Hello! I'm so happy you're here and cannot wait to meet you! Please fill out the consultation forms before you book your appointment with me. For both your safety and mine, I need to make sure that all paperwork is properly taken care of. If consultation forms are not filled out, as stated on my website, I will not perform your service until everything is completed. Thank you in advance and I will see you in my treatment room real soon!
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Gender
Male
Female
Prefer not to say
Are you 18 years of age or over?
*
Yes
No
How did you hear about me?
*
Instagram
Bare Beauty / Online
TikTok
Referral
Other
If you were referred or selected other, please respond in detail:
Medical History
[Do you have a history of any of the following medical conditions for brows? Please select any or all that apply to you.]
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Currently undergoing Chemotherapy/ Radiation
Prone to erythema
Bruises easily
Dry Eye Syndrome
Rosacea
Eczema
Psoriasis
Recent Botox/Surgery/Face Life
Anxiety
Allergies to adhesive tape, fumes or eye remover
Ultra sensitive skin
Sunburn
Wounds in the treatment area
Other
Do you consent to have your eyes closed and covered for the duration of 45-65 minutes of the procedure?
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Yes
No
Do you wear contacts/glasses?
*
Yes
No
Do you have any known allergies?
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Yes
No
If yes, please detail:
Have you had work done on your brows before?
*
Yes
No, First time!
If yes, when was the last time you received a brow treatment and what type was it?
Is there anything else that you want me to know before providing you with your brow service to make it more comfortable or beneficial for you?
I understand that I can be exposed to chemicals that are used for beauty and cosmetic benefits.
Yes, I understand
Photo & Video Release:
I hereby give Essence SkinBar permission for any photos, videos, or audio that are taken of me to be used in and/or for any lawful promotional materials, such as but not limited to newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media pages, and other print and digital communications.This authorization shall continue indefinitely and extends to all languages, media, formats and markets now known or later discovered.I renounce all claims I may have to royalties or other forms of payment resulting from or connected to the use of the image or sound recording.I understand and agree that these materials shall become the property of Essence SkinBar and will not he returned. By signing below, I hereby acknowledge that I have completely read and fully understand the above release agreement. In addition, I understand that I will not receive financial compensation for photos or videos that may be taken during this facial treatment.
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Yes, I understand and agree.
Terms and Conditons
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that if I withhold some important information from Essence SkinBar and complications happen, the clinic will not be liable. I fully read and understand the cancellation, no-show and rescheduling policies. I release Essence SkinBar and hold harmless against any claims, expenses, damages, and liabilities. I understand that by booking and entering my card information, I am authorizing Essence SkinBar to charge my card fees associated with no-show and late cancellation policies. I understand that I can view cancellation policy details on Essence SkinBar's website.
*
Yes, I understand and agree.
Name
*
First Name
Last Name
Enter today's date:
*
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Month
-
Day
Year
Date
Submit
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