PRE-SCREEN Client Consultation, Medical Health, Patch Test Waiver & Photography Consent Form for Brow Services

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DateToday’s Date
Date
Month
Day
Year
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NameClient
First Name
Last Name
3
Are you over the age of 18?You must be 18 or older for Permanent Makeup Services.
YESNO
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number* This field is required.
Area Code
Phone Number
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Email* This field is required.* This email address will be used for main correspondence, including appointment booking information.
example@example.com
7
Instagram/ Social Media Name
8
How did you hear about me?
9
Have you previously had a micro shading/ blading procedure performed on your eyebrows?
YESNO
10
If you answered "yes", please provide detailsService type (microblading/ microshading) & time frame
11
What would you like to improve or correct on your eyebrows?Think about shape, colour, density, thickness of your brow
Huge
Large
Normal
Small
Ok
Ok
12
What's your skin's reaction to the sun without SPF?Fitzpatrick Scale Reference
Fitz. 1 Always burns, never tans
Fitz. 2 Usually burns, rarely tans
Fitz. 3 May burn, but burn will turn into a light brown tan
Fitz. 4 May burns, but burn will turn into a dark brown tan
Fitz. 5 Rarely burns, usually tans
Fitz. 6 Always tans, never burns
13
How would you describe your skin typeThis will help determine which permanament makeup technique may be better for you
Dry Skin
Oily Skin
Combination Skin
Other Skin Type
14
How would you describe your face shape?This will help to determine the brow shape that better compliments your face shape.
Oval - Slightly longer than wider. Cheekbones are the widest part of the face. Jaw & forehead are rounded and sides of the face are slightly curved.
Heart - Width of forehead & cheekbones are wider and thinner than chin area
Round - Wider along the center and the jawline. Jawline is rounded
Square - Jawline is strong & squared off
Rectangle - Oblong face. Hybrid of the oval and square shape
Other
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Have you had an allergic reaction to any of the following* This field is required.Please select any that may apply
Lanolin (Aquaphor)
Latex Rubber
Vaseline
Medication
Metals
Hair Dyes
Paints Crayons
Glycerine
Lidodan (anesthetic)
Lidocaine (anesthetic)
Tetracaine (anesthetic)
None of these apply to me
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Please select all that apply to you
Retin - A within the last 2 weeks
Sensitivity to cosmetics
Anemia
Hepatitis
Diabetes
Haemophilia
HIV / AIDS
Bleed Easily
Artificial Heart Valves
High Blood Pressure
Low Blood Pressure
Prolonged bleeding
Liver Disease
Circulatory Problems
Fainting spells or dizziness
Epilepsy
Tumors, growths, cysts
Thyroid Disorder
Trichotillomania (Hair pulling)
Hair loss
Alopecia
Cancer
Chemical or laser peel within 6 weeks
AHA preparations in the last 2 weeks
Fat Injections, Botox Injections, Collagen Injections
Hypertrophic Scars Keloid Scars
Healing Problems
Scaring Easily Bruise Easily
Pregnant or Nursing
Hormone Imbalance
Hepatitis A/B/C
Spinal Injury
Cold Sores
Blood Clot Disorder
Immune Disorder
Skin Disease/ Disorder
Rosacea
Psoriasis
Pacemaker/ Defibrillator
Varicose
Depression
Claustrophobia
OTHER
NONE OF THESE APPLY TO ME
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Are you pregnant or breast feeding?* This field is required.PMU may invite the possibility of infection and can be passed on to your baby. Hormones also affects the healed results.
YESNO
18
Have you taken the Covid - 19 Vaccine? Only once the body builds full immunity should PMU procedures be performed. Appointments can not be made in between the first and second dose. You must book your appointment at least 4 weeks after the second dose.
YESNO
19
If you answered "Yes", is your appointment booked 4 weeks after you've taken the second dose?If NO you may have to reschedule your appointment
YESNO
20
Are you currently under the care of a physician or dermatologist?Certain doctor prescribed medications or facial creams/serums may affect the application of the service and the healing process. Some contraindications may require a note from your physician.
YESNO
21
If you answered "Yes", please provide details.Primarily related to skin or hormones
22
Have you had radiation or chemotherapy in the past year?If you answer yes, your appointment will need to be booked at least 1 year after your last treatment.
YESNO
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Do you currently use or have you used any of these in the past 3 months? Products that contain Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA (Alpha hydroxy acid) /BHA (Beta hydroxy acid), Salic Acid, Lactic Acid Retinol/vitamin A, Accutane or any other prescription or over the counter skin products
YESNO
24
If you answered "Yes", please provide details
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Please provide details of your daily facial routine?Include any types of creams and facial products that you use on your face.
Huge
Large
Normal
Small
Ok
Ok
26
Have you had any dermal injections/ fillers such as Botox, Restylane or Collagen injections in the last 6 months?This information helps to determine how it may effect your brow placement. Injectables can alter the position of the eyebrows.
27
Do you smoke regularly?This information helps to know how it may effect your healing process.
YESNO
28
Will you be involved in any activities that will make you sweat including exercise, pool, sauna & etc?* This field is required.You will have to avoid some activities for 7 to 10 days after PMU application while your brows are initially healing to retain the pigment.
YESNO
29
Do you spend extended periods of time exposed to the sun on a regular basis?This is helpful to know for the healing process/ outcome.
YESNO
30
Do you follow a restricted diet that may affect your healing?Low protein, Vitamin C restricted & etc. This helps determine how your diet may effect your healing process.
YESNO
31
If you answered “Yes”, please elaborate
32
Are there any major concerns relating to your eyebrows or skin reactions that should be noted? If yes, please provide details.
Huge
Large
Normal
Small
Ok
Ok
33
Photographic Consent I consent to photographs being taken before, during and after each procedure. I agree to these photos being stored electronically and will be used only with my written consent for promotional purposes.
Yes. I do Consent
No. I do not Consent
34
SignaturePlease Sign for Photographic Consent
Clear
35
Patch Test Waiver* This field is required.Patch Test Waiver: (please read carefully) (A) I understand that a skin test can determine whether or not I will experience a reaction to the products used within 48 hours prior to the treatment. However, I accept this will be inconclusive as to whether I have an allergic reaction at any time in the future. (B) I have undergone or been offered an allergy test prior to my initial treatment. I therefore release Shawanna Francis Muir/ Alternative Beauty Artistry from liability related to any the allergic reaction I may experience associated with either the application of the pretreatment cream or any other products used before, during and after my procedure, immediately or at a later date.
I therefore waive my option to an allergy test and wish to proceed with treatment.
I would like to proceed with an allergy test. I am aware that this may delay my initial appointment until after the allergy test is completed and and additional $10 fee will be applied to the service.
36
Signature* This field is required.Please sign for Patch Test Waiver
Clear
37
Are you aware of the brow healing phases after your PMU procedure? (Please view the following images)* This field is required.
YESNO
38
Ghosting PhaseEveryone heals differently after their PMU procedure. These images illustrate some of the normal healing phases that you may go through. If you plan to attend any special events within days 2 to 15 after your PMU session you may want to postpone your appointment or choose an alternative brow service such as henna or brow lamination.
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Daily Healing StagesEveryone heals differently after their PMU procedure. These images illustrate some of the normal healing phases that you may go through. If you plan to attend any special events within days 2 to 15 after your PMU session you may want to postpone your appointment or choose an alternative brow service such as henna or brow lamination.
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Healing Emotions You may go through all of these emotions but it will be worth it when you’re healed and always ready to go!
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Client Consent* This field is required.I understand , have read and complete the questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/ or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential. The treatments I received here are voluntary and I release Alternative Beauty Artistry from any liability and assume full responsibility thereof.
I have fully understood the information provided above. I confirm that all of the information provided by me is correct and truthful.
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Covid -19 Safety Measures* This field is required. MASKS ARE MANDATORY! Mask must be worn during appointment and hands washed on arrival. No additional guests permitted. Please wait in your vehicle until appointment time. All clients must sanitize upon entry and your temperature will be taken (must be lower than 37 degree Celsius). There will be limited conversation during your appointment procedure. If you have been ill or are experiencing symptoms of illness (fever,cough, shortness of breath), have been around anyone who has been ill within the last 14 days or if you travelled internationally within 14 days, please reschedule your appointment. Thank you for your understanding.
I understand and I agree to these COVID 19 Measurements
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Please Upload a Current Picture of your Face with Your Bare Eyebrows.NO MAKE- UP OR FILTER
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Signature * This field is required.I certify that I have read, understand and answered all questions to the best of my knowledge. I fully understand and agree to the above Consents including Patch Waiver Test, Photography, Client Consent, & COVID 19 Safety Measures. I will proceed to have permanent cosmetic enhancement of my own free will.
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Please Add Your Availability * This field is required.Please indicate time and dates that in order to accommodate you for an appointment
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Pre - Care Instructions

Please Take a Screenshot for Future Reference

Covid- 19 vaccination - Please wait 4 weeks before, after and in between doses.

• Do not work out 24 hours before procedure.

• NO alcohol or caffeine 24 hours before procedure (Yes, there is caffeine in decaf coffee and tea!).

• Avoid sun and tanning one week prior to procedure.

• Do not take Aspirin, Niacin, Vitamin E or Advil/Ibuprofen 24 hours before procedure.

• Avoid power shakes and power greens, Fish Oil, and "Hair, Skin, Nail" supplements 24 hours prior to procedure.

• Discontinue Glycolics, Chemical Peels and Retin-A 4 weeks prior.

• Refrain from use of any Alpha Hydroxy Acid (AHA) products close to the eyebrow area 2 weeks prior to and 2 weeks after your procedure. Check your moisturizer, facewash BB (blemish/ beauty balm) or CC (colour correcting) creams and makeup primers for anything that says acid.

• No brow waxing or tinting one week before.

• Please Note: You will be more sensitive during your menstrual cycle.

• You have to be off any kind of Accutane for 1 year. NO Exceptions!

• No Latisse (on brows) for minimum of three weeks prior to permanent brow.

• Fillers should be done six weeks prior to scheduled procedure or six weeks after procedure.

• Botox should be performed two weeks prior to scheduled procedure or two weeks after.
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