Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone Number *

(###)

###

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I UNDERSTAND THAT MICROBLADING & PERMANENT MAKEUP IS NOT GOOD FOR THOSE WHO: *

- Are taking antibiotics. - Are prone to keloids. - Are pregnant or nursing. - Have had shingles on the face. - Have auto-immune disorders (require doctor's consent). - Have heart conditions, a pacemaker, or defribillator. - Have eczema, psoriasis, or dermatitis in or around the brow area.

Agreed

PRIOR TO MY APPOINTMENT *

I understand this information is CRITICAL to my healed results! - Do not work out the day of the procedure and no heavy sweating for 5 days after. Salt in sweat will affect retention. - Do not tan 30 days pre/post or have a sunburned face. - Do not take Aspirin, Niacin, Fish Oil, Vitamin E or IBUprofen for one week before procedure. - No alcohol or caffeine on the day of or before the procedure. - Please note that you will be more sensitive during your menstrual cycle. - Botox must be done 2 months prior to service. - No chemical peels for 30 days pre/post treatment. - Avoid ANY skincare products or treatments that are anti-aging, lightening/brightening, oil-absorbing, or used to treat acne/congestion for 30 days pre/post treatment. This especially includes ingredients like retinol, glycolic, salicylic acid, and benzoyl peroxide.

Agreed

Do you have a previous brow tattoo? *

Yes

No

Explain your skin type by checking all of the appropriate boxes below. *

Fair

Medium

Dark

Thin

Thick

Dry

Normal

Combination

Oily

Sun Damaged

Congested - prone to blemishes

Do you have any of the following? *

Glaucoma or other eye disease/disorder

Heart Conditions/Defribillator/Pacemaker

Diabetes requiring insulin

Problems with healing

Keloids or Hypertrophic scarring

Seizures

Eczema, Psoriasis, Dermatitis or any other skin disease

Autoimmune Disorder

Trichotillomania

Alopecia Totalis or Areata

Allergies - detail below

Active cold sores/irritation of the skin of any kind

Viral infections or diseases

None

Are you? *

Pregnant or Nursing

Planning on cosmetic surgery

Currently under the care of a physician

Undergoing Chemotherapy

Taking antibiotics

None

Do you use? *

Accutane within the last year

Antibiotics prior to dental procedures

Steroids

Retin-A, glycolic acid, vitamin c, exfoliants

Tanning Beds

Latisse

Chemical Peels - When?

Blood Thinners

None

CHANGE IN HEALTH *

It is your responsibility to inform us if there are any changes to your physical condition after this form is completed. If you show up to your appointment and we are unable to go forward with the procedure either due to changes to your physical condition that you have not informed us of, or you failed to follow PRE-CARE instructions, or you are unable to follow AFTER CARE instructions, you will lose your deposit.

Agreed

FRIENDS OR FAMILY MEMBERS ARE NOT ALLOWED IN THE TREATMENT ROOM. *

Agreed

COST - Pricing is $350 for powder brows which is broken into two payments; $100 deposit and the remaining balance at the time of service. A touch-up appointment is necessary within three months of the initial appointment and will cost $150. *

I understand

I understand and accept that this service is a process and may require multiple applications in order to achieve the desired result. If I request any adjustments to my permanent makeup within 3 months of my touch-up appointment it will require a minimum $50 fee to cover supplies and set-up. *

Agreed

I understand the skin has many variables and it is impossible to achieve 100% symmetry and equal color saturation. *

Agreed

Touch-ups are necessary in order to retain your pigment for 12-24 months. If you have not reserved a touch-up appointment within three months of your initial service and the pigment or shape is not visible, you will be required to start over. *

Agreed

*CANCELLATION POLICY* I understand that I must allow 48 hours prior to canceling or rescheduling my appointment. If I am unable to cancel in the required time, do not arrive to the appointment date on time, fail to include information about myself or do not follow pre-care instructions and service guidelines, my deposit will be forfeited. If a scheduling issue arises, you may change your appointment however, multiple reschedules will result in losing your deposit. Deposit is valid for one year from purchase date and non-transferable to other services/products. *

Agreed

By typing my FULL NAME below, I acknowledge all information contributed by me is true, to the best of my knowledge and is stated on this record. I agree to inform The Browtique should there be any changes prior to my treatment. *

First Name

Last Name