Ombre Powder Brow Consultation Form
THIS IS NOT AN APPOINTMENT. THIS IS A CONSENT/CONSULT FORM. To book, please visit montxesthetics.glossgenius.com before submitting this form. All new clients must submit this form within 24 hours of your appointment request (via aforementioned link) in order to be accepted. If you have not been serviced by Mont. Esthetics for more than a year, you are considered a new client.
Disclaimer
I currently do not accept clients with previous work done. I may be able to accommodate those with very faded work that was done year ago. In this from, please submit a photo and information regarding your brow history so I can help you more efficiently. If a consultation appointment is booked without this form and the previous work is dark and bold, the consult fee will still be charged. Additionally, the style of brow I deliver is a more feminine style. I am happy to service anyone who is looking for this style. Please reference my instagram or portfolio on my website to view my work.
Select Service
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Please Select
Session 1
Session 2
Yearly touch up
Color Boost
Touch up + Color Boost
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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Month
-
Day
Year
Date
Age
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Gender
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Female
Male
Fluid
Pronouns
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Email
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example@example.com
Instagram @
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If none, put NA
Preferred Language
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English
Spanish
Do you wish to conduct an allergy patch test prior to procedure? NOTE: If yes, full service cannot be done same day.
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Yes
No
Emergency Contact
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Include full name, phone number, and relation
Have you received Chemo Therapy in the past year?
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Yes
No
Are you currently taking any medications?
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Yes
No
Please list any mediation you have taken in the past 6 months and their purpose.
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Do you have any allergies?
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Yes
No
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
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Are you pregnant?
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Yes
No
Are you breastfeeding?
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Yes
No
Do you have any implants?
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Yes
No
Do you have any Botox or other injectables?
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Yes
No
Do you participate in outdoor recreational activities?
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Yes
No
If so, do you understand that you need to protect your cosmetic tattoo from sweat, water, and direct sunlight?
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Yes
No
Please check below if you have the following medical condition:
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Rows
Yes
No
Remarks
Hair Loss
Trichotillomania
Alopecia
Prolonged Bleeding
Cancer
Low Blood Pressure
High Blood Pressure
Liver Disease
Sensitivity to Cosmetics
Circulatory Problems
Thyroid Disturbances
Anemia
Fainting Spells or Dizziness
Hyperpigmentation
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
HIV positive
Venereal Disease
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia
Hypertrophic or Keloid Scars
None of the above
Have you had any type of Permanent Make Up procedures on your brows before?
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Yes
No
If so, please explain
If so, when did you have it?
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Month
-
Day
Year
Date
Have you had a Chemical or Laser Peel within 6 weeks?
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Yes
No
Have you taken Accutane in the last year?
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Yes
No
Have you used a Retinoid, Retin-A, Differin, Renova, Benzoyl Peroxide, Salicylic Acid, Tretinoin or similar in the last 14 days? If so, which one?
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If none, put NA
How did you hear about us?
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Instagram
Facebook
Google
Referral
What are your main concerns relating to your eyebrows? What would you like to improve?
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Please be as detailed as possible
Please upload a photo of your eyebrows without make up using the back camera of your phone and flash/natural lighting.
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Pre-Procedure Care
2 WEEKS PRIOR: Avoid waxing your eyebrows (waxing removes the very first layer of the Epidermis leaving your skin very irritated and sensitive), exfoliating your skin, products that contain glycolic acid, VITAMINS A & C, Retinol, and chemical peels. DAY PRIOR: Avoid alcohol and any medications that will thin the blood. Thinning of the blood may cause bleeding during the service thus affecting how the skin holds the pigment and creating inconsistent results. DAY OF: Do not drink any caffeinated drinks including coffee, teas, energy drinks, etc.
Post-Procedure Care
It not recommended to schedule an Ombre Powder Brow session prior to a special event or trip. Similar to a regular tattoo, expect your brows to scab up and peel. Keep your brows bare! Don’t use any creams, oils, or makeup during healing (except for healing creams like Afterinked if instructed.) AVOID SWEATING OR WETTING! This includes swimming. You can continue showering and/or washing your face while lathering around the brows. If you spend much time outdoors, use SPF (on the skin only) and a hat/cap to avoid direct sunlight on the brows. Once the brows have healed, apply SPF on the brows for a longer-lasting color. If you do sweat, you may gently wash the area with mild antibacterial soap + lukewarm water to avoid an infection. It is recommended to stop the use of all heavy chemical exfoliants (Retinol, Tretinoin, Alpha Hydroxy (AHA), Vit. A) as they will significantly lighten results. Please note that this is an average timeline of the healing process. It is not guaranteed that your skin will heal this exact way. MORE DETAILED INFORMATION WILL BE SENT TO YOU VIA TEXT.
Acknowledgement
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I understand that this procedure cannot guarantee 100% expected results.
I allow the center to take photographs for case review which is before and after.
I allow the center to use this photograph for a marketing campaign or advertising.
I release the center for any liabilities related to the treatment and result specifically allergic reactions and applied pigmentation.
I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.
I understand that permanent and semi-permanent cosmetics are a form of tattooing.
I confirm that a healing period is required before the next or before the touch-up treatment.
I understand that this procedure might be painful and requires patience.
I understand that there might be an allergic reaction with or without conducting a patch test.
I understand that I might experience infection, minor bleeding, swelling, and redness.
I confirm that I have read, understand, and answered this consultation form accurately.
I confirm that I answered all questions truthfully and correctly.
Please upload a photo of your valid government ID.
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Signature
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Date Signed
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Month
-
Day
Year
Date
Artist Signature
This is for the Artist only. Please do not sign.
Submit
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