Client Questionnaire & Consent Form
Brow Treatment
Client Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Medical History
Are you currently taking any medications?
*
Yes
No
If you answered yes, please specify
Do you have any allergies to cosmetics, food or drug?
*
Yes
No
If you answered yes, please specify
Are you currently pregnant, nursing or trying to conceive?
*
Pregnant
Nursing
Trying to Conceive
N/A
Please check if you are affected by or have any of the following
*
Accutane
Acne Topicals
Antibiotics
Cancer
Diabetes
Eczema
Hemophilia
Hepatitis A/B/C
Herpes Simplex
HIV/AIDS
Lupus
Psoriasis
Thyroid/Hormone Issues
Staph Infection/MRSA
N/A
Have you gotten recent treatments within the past month? Ex: Botox, Laser Hair Removal, Tanning Beds, etc.
*
Yes
No
If you answered yes, please specify
Are there other health/skin concerns we should be aware of?
*
Yes
No
If you answered yes, please specify
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Brow History
Have you had your brows tinted, waxed and/or laminated?
Yes
No
If you answered yes, when was the last time you got them done?
Have you had an adverse reaction when getting your brows done?
Yes
No
If you answered yes, please specify
Is there anything else we should know about you, your preferences or your brows?
Yes
No
If you answered yes, please specify
Do you give permission to be filmed or have photos taken of your treatment?
Yes
No
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Acknowledgement & Release
By signing this form, the client agrees to the following: I understand, have read, and completed this questionnaire, truthfully and agree to inform the technician of any changes in the above information. I agree that this constitutes full disclosure and that it supersedes any previous verbal or disclosures. I understand that withholding information or providing this information may result in contraindications and or irritation to the skin from treatments received. The treatments I received here are voluntary and I release this institution and or skincare, professional from liability and assume full responsibility there of. I am aware of the policies and am compliant to paying cancellation, late & no show fees if needed.
I understand, have read & agree to the policies
*
Signature
*
Date
*
-
Month
-
Day
Year
Submit
Submit
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