Brow Catching Intake Form

Please fill out the following form.

First name

Last name

Email

Date of birth

Month

Day

Year

Address

Phone

Emergency Contact Name and Number

Are you suffering from a medical condition, illness or injury?

Yes

No

Have you been hospitalized in the last 12 months?

Yes

No

Do you have any allergies

Yes

No

Are you or could you be pregnant

Yes

No

Are you breastfeeding

Yes

No

Are you on any medications?

Yes

No

If you answered yes to any of the medical questions above, please supply additional information. (name of medications as well)

EYEBROW QUESTIONS: Do you have or have had any of the following conditions: Childbirth in the last 120 days, Diabetes, Healing Problems, Bleeding Disorders, Eczema, Low Blood Pressure, Sensitive Eyes, Cancer/Chemo, Cataract, Autoimmune Diseases (Lupus)

Yes

No

It's essential to obtain a doctor’s consent before undergoing permanent makeup if you have any of the medical conditions listed above, take specific medications, or are recovering from recent procedures. This ensures your safety. Do you consent?

Yes

No

File upload

Doctors Consent

Have you ever had eyebrow treatment before?

Yes

No

Do you use any of the following products on your eyebrows? Pencils, Powder or Other

Yes

No

If yes: we they applied by a professional?

Yes

No

If you answered yes to any of the medical questions above, please supply additional information.

BODY CONTOURING QUESTIONS: Do you or have you had any of the following conditions: Autoimmunie disease, Back/Neck Pain, Cancer/Chemo, Cardiovascular conditions, Diabetes, Epilepsy, Gallbladder removal, High blood pressure, History of gallstones.

Yes

No

If you answered yes to any of the medical questions above, please supply additional information.

Do you drink water daily?

Yes

No

If so how many ounces a day?

Do you drink alcohol?

Yes

No

If yes; once a month, 2-4 times a month, 2-3 times a week, or 4+ times a week?

Brow Catching has my permission to use my photograph publically to promote the practice. I understand that the images may be used in the print brochure, website and social media. At no time will we show a customers face or name during sharing.

Yes

No

By signing below, you confirm the following: The information provided in this form is accurate and complete to the best of your knowledge. You agree to update the technician with any changes to the information above. You confirm that you do not have any conditions that would make the requested treatment inappropriate. You release the technician from any liability for injuries or damages resulting from any misrepresentation of your health.

By signing below, you acknowledge and agree to the following: You understand that receiving these services with the specified conditions may impact the outcome of the procedure. Any additional services required due to these conditions listed above will be at your own expense.

Date

Month

Day

Year

Type Name

Signature

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