Brow and Beauty Ink - Facial Treatment Consent Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail Address*

Mobile Phone Number*

How did you hear about us?*

Are you pregnant or trying to become pregnant?*

YesNo

Are you at least 12 years of age?*

YesNo

Date of Birth*

Emergency Contact Name and Number

Please list all the medications taken within the last 6 months

What are your current skin concerns?*

	Yes
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skintone
Sun, Liver, Brown Spots
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Redness/Ruddiness
Broken Capillaries
Dull Dry Skin
Dehydrated
Rosacea
Another Allergy
None

Other skin concerns not listed above.

Other health concerns not listed above.

Do you have any of the allergy risks below?*

	Yes
Animals
Cosmetics
Food
Fragrance
Latex
Medicine
Iodine
Pollen
AHAs
BHAs
Shellfish
Sunscreen
Another Allergy
None

If 'yes' or 'another allergy' please provide additional information below

What is your skin type?*

What is your average exposure to the sun?*

NeverLightModerateExcessive

How does your skin heal?*

Do you use tanning beds?*

NeverLightModerateExcessive

Do you bruise easily?*

YesNo

Have you ever had a facial treatment before?*

YesNo

Have you used Renova, Retin-A, AHAs or Retinol/Vitamin A derivative products in the last 3 months?*

YesNo

Have you received Collagen, Restylane, Botox or Filler injections in the last 6 months?*

YesNo

By signing below, you agree to the following:

I have completed this questionnaire truthfully and to the best of my knowledge. I understand that withholding information or providing inaccurate details about my medical history, allergies and medications may lead to adverse reactions to the treatments I undergo. I agree to inform the technician of any changes in the above information.

I agree to Above Statement*

I hereby confirm that I am of legal age over 12 years old and that I am not under the influence of drugs or alcohol. I also affirm that I am not presently pregnant or nursing. I willingly provide my consent for the facial treatment that has been discussed and specified.

I have voluntarily elected to undergo this facial treatment after the nature and purpose of this treatment have been explained to me, along with the risks and hazards involved.

I attest that I have read the preceding paragraphs, initialed them, and understood the consent and procedure allows. I fully acknowledge that I made the decision to get this facial treatment done.

My signature acknowledges that I have read and agree that I will adhere to all of the aforementioned statements that I have initialed.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results that independent results are dependent upon age, skin condition, and lifestyle, and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. If I will have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently using. I have read and fully understand this agreement and all the information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

I agree to Client Consent Form*

Payment Policy

Brow and Beauty Ink accepts all major Credit Cards, Debit Cards, Cash (exact), Cash App, and Venmo. No personal checks or money orders. The total balance will be due upon service completion.

Cancellation Policy

While we are ever so grateful for our wonderful clients, timely and efficient services are a must to provide outstanding customer service. Customer satisfaction is our highest priority, and these policies exist to give all clients the absolute best experience possible.

For all SPMU appointments, a 48-hour notice is required to cancel or reschedule your appointment; we ask that you please call; a voicemail, text, or email is sufficient. Should you fail to cancel or reschedule your appointment at least 48-hours prior you will forfeit your deposit. You will be required to pay another deposit to reschedule your appointment.The full balance of the scheduled service will be charged to the card on file for no-show, no call clients.

All other beauty appointments require a 24-hour notice cancel to cancel reschedule your appointment. Should you fail to cancel or reschedule your appointment at least 24-hours prior you will be charged 50% of the service fee. The whole cost of the service will be charged if you cancel without giving any notice or fail to show up for your appointment.

A 15-minute grace period is provided for each appointment. If your anticipated arrival time exceeds the grace period, you will be asked to reschedule. Arriving more than 15 minutes late to your appointment will be considered a no-show client.

There will be no exceptions to this policy. By booking your appointment with Brow and Beauty Ink you acknowledge that you have read, understood and agreed to the Cancellation Policy.

Refunds

There are no refunds for any services.

I agree to Payment and Cancellaion Policy*

Notes

Brow and Beauty Ink Skincare Consultation Form

Facial Treatment Client Consent Form

Cancellation Policy Form

Esthetician Authorized Notes