Brow Lamination Intake/Consent Form
If you have any of the following: open wounds such as acne, eczema, psoriasis or pregnancy I will not be able to move forward with your brow lamination.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Appointment Date?
*
-
Month
-
Day
Year
Date
Personal Information:
Are you 18 yrs or older?
*
Yes
No
Have you ever had brow lamination?
*
Yes
No
If so, have you had any reactions?
Have you ever had an allergic reaction to hair perming products?
*
Yes
No
If so, have you had any reactions?
Are your brows Microbladed?
*
Yes
No
If yes, when did you get them done?
Are you currently using any skin care or exfoliating products around the eyebrows?
*
Yes
No
Have you recently bleached or tinted your eyebrows?
*
Yes
No
If yes, when did you get them tinted or bleached?
Are you being treated for any kind of injury?
*
Yes
No
If yes, when and what did you get done?
Will you be getting a brow tint with your brow lamination?
*
Yes
No
If you answered yes, have you ever had any reactions after getting a brow tint?
Medical History:
Do you have skin Sensitivity or allergies?
*
Yes
No
Are you taking any skin medication?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Do you have any of the following conditions? (please select all that apply)
*
Eczema
Diabetes
Pscoriasis Around the Eyes/Psoriasis
Recent Eye Infection
Sunburn
Recent Eye Surgery
Sensitive Skin
None
Please list any illness or condition you are being treated by a physician for:
SKIN CARE HISTORY
Please select your skin type: (You can check off more than one)
*
Normal skin
Oily skin
Dry skin
Sensitive
Unsure
Have you had a chemical peel, laser or microdermabrasion done within the last 30 days on or around your brows?
*
Yes
No
SKIN CARE HISTORY OF USE EVERYDAY:
*
Cleansing Cream
Eye Cream
Facial Scrub
Night Cream
Day Cream
Exfoliants
Skin Toner
Eye Makeup Remover
Facial Soap
None
Terms & Conditions
I use Instagram (@bareskinglowstudio) for promotional proposes. Do you consent photos/videos during your service?
*
Yes
No
By signing below, I agree to the following:I have completed this form to the best of my ability and knowledge. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform Elsa (Bare Skin Glow Studio) of any discomfort I may experience at any time during my treatment to allow her to adjust accordingly. I agree to waive all liability toward my technician Elsa (Bare Skin Glow Studio) for any injury or damages incurred due to any misrepresentation of my health.
Today's Date:
*
-
Month
-
Day
Year
Date
E-Signature
*
Continue
Continue
Should be Empty: