Brow groomingPlease open and review this intake form. Complete a submission after booking any brow grooming services. Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Medical Questionnaire Birthdate * MM DD YYYY I have used/am currently using: Please check any of the following that apply to you. Skin or blood thinning agents within the last 48 hours Exfoliating acid or retinoid (Retin-A) products within the last 2 weeks Accutane within in the last 6 months Tanning - tanning beds or sunbathing Open skin lesions near the wax area Please list any allergies you have. Please list any medications you are currently on. Please list any illnesses or medical conditions you are currently being treated for by a medical professional, including current treatment for cancer. Consent Date * MM DD YYYY Please submit. * Note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc. If an unforeseen condition arises in the course of the procedure, I authorize Khrista to use her professional judgement to decide what she feels is necessary under the given circumstances. I understand dyes and solutions have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. I have been advised how long the results may last and understand that the results achieved have no guarantee. I understand the nature of the procedure and adverse effects that may occur as a result of applied dyes and solutions. I have been informed that the highest standards of hygiene are met and that new items or disinfected reusables are used for each individual client, procedure, and visit. I agree to read the aftercare instructions that been provided and explained to me by Khrista. I understand that achieving the results I desire will, in some measure, be determined by my compliance to these instructions. I have been given the opportunity to ask questions about the procedure, equipment, past experience, and the methods to be used, as well as, the risks and hazards involved. I believe that I have sufficient information to give this informed consent. I understand the taking of before and after photographs of procedures maybe required and that some photographs may be taken during the procedure. I also understand that exceptional photographs or results may be used in advertising or promotional materials and give permission for such usage. - I have read and fully understand the above information. I have given an accurate account of the questions. If I have any concerns, I will address these with Khrista. I give permission to Khrista to perform the service we have discussed. I agree to adhere to the aftercare instructions as recommended by Khrista. I understand that Khrista will take every precaution to minimize or eliminate negative reactions as much as possible. Despite all precautionary measures Khrista takes, injury is possible. I will hold Khrista harmless from any liability, responsibility, damages or issues that may result from this service. Yes, this submission certifies that I agree to all clauses stated above. Thank you for submitting!
