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Powder Brows Questionnaire
Date
MM slash DD slash YYYY
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Birthday
(Required)
MM slash DD slash YYYY
Phone
(Required)
Email
(Required)
Confirm Email
Emergency Contact
(Required)
First
Last
Emergency Contact Phone
(Required)
Who referred you?
(Required)
Do you have any known allergic reactions or sensitivities to any topical or local anesthetics?
(Required)
No
Yes
Are you allergic to lidocaine or any other numbing agents?
(Required)
No
Yes
Do you have any allergies (i.e. Polysporin, Bacitracin, Neosporin, Latex, etc.)?
(Required)
No
Yes
Are you currently pregnant or breast-feeding?
(Required)
No
Yes
Do you bruise easily?
(Required)
No
Yes
Does your skin swell easily?
(Required)
No
Yes
Do you have any heart conditions or high blood pressure?
(Required)
No
Yes
Do you have or do you think it is possible that you have any blood borne communicable disease such as HIV or Hepatitis?
(Required)
No
Yes
Do you have any serious medical conditions?
(Required)
No
Yes
If yes, please describe here:
Do you have diabetes, currently on any form of immunosuppressant therapy or any condition that may delay healing?
(Required)
No
Yes
Do you suffer from any form of hyperpigmentation (dark spots)?
(Required)
No
Yes
Do you have any known personal history or family history of Methemoglobinemia (blood disorder)?
(Required)
No
Yes
Have you ever had a Herpes Simplex Type 1 infection?
(Required)
No
Yes
Do you use Retin A or Glycolic Acid products?
(Required)
No
Yes
Are you prone to keloid scarring or any other form of excessive scarring condition?
(Required)
No
Yes
Do you have a bleeding disorder or take blood thinners?
(Required)
No
Yes
Are you allergic or sensitive to any metals?
(Required)
No
Yes
Have you had any form of cosmetic or surgical procedure (botox, injections, laser therapies, facelifts, etc.), Radiotherapy or Chemotherapy at any time within the last 6 months?
(Required)
No
Yes
Do you have any chronic or acute eye disease?
(Required)
No
Yes
I agree to the following Powder Brows post-procedure and healing instructions: • Don’t touch, scratch or rub them • No Makeup on brows • Don’t pick the scabs • Don’t sleep on your face • Avoid excess sweating • Avoid dust and dirt
(Required)
Acknowledge
I understand and acknowledge that Angelique Swann Esthetics & Wellness Solutions, et.al. has explained the nature of the procedure, including the risks and dangers inherent therein. I HEREBY CONSENT to Angelique Swann performing powder brow treatment and its procedures on me, and in consideration of her doing so, I hereby release and forever discharge Angelique Swann from all demands, damages, actions or causes of action arising out of the performance of said treatment procedures, which I, my heirs, executors, administrators or assign, can, shall, or may have. No refund on any treatment. I accept the color, design, and payment terms in this contract.
(Required)
Acknowledge
Angelique Swann Esthetics & Wellness Solutions has a strict 24-hour cancellation policy. Your appointment time is reserved exclusively for you. Communication is crucial if you need to cancel or reschedule your appointment. In the event of a late cancellation the fee is the cost of your appointment or $50.00, whichever is less. If appointment is cancelled same day or no show, the fee is 100% of scheduled service. PLEASE NOTE: Saturday appointments now require a 3 day (72 hour) notice to reschedule or cancel. An invoice will be sent, which is due upon receipt. If I am able to replace appointment with a client on wait list, I am happy to waive the fee.
(Required)
Acknowledge
CHECK-IN: To ensure your full treatment time please allot a few extra minutes to navigate parking so you can arrive 5 minutes early to your appointment. Arriving 15 minutes (or more) late will need to be rescheduled and are subject to a cancellation fee*.
(Required)
Acknowledge
MEDICAL CONCERNS: You will be asked to disclose any diagnosed medical conditions and medications in your client profile intake form. All information is strictly confidential. Full disclosure is required for your safety in the treatment room.
(Required)
Acknowledge
FACILITIES & PARKING: Conveniently and centrally located near downtown Dallas inside the South Side on Lamar building. There is free parking out front, and also 2 free retail lots nearby. There is also metered parking on the streets surrounding the building.
(Required)
Acknowledge
Photo Release: Permission is granted to take before and after photos of my brows / face which may be used for marketing purposes on a website, salon or class.
(Required)
Yes
No
Yes! I would love to be added to Angelique Swann Esthetics & Wellness Solutions newsletter for relevant information, timely topics and special savings offers to enhance your life.
Acknowledge
Please note any additional information that may be of importance to your esthetician regarding the treatment you may be receiving.
Signature (your name submitted below will be considered your electronic signature.)
(Required)
First
Last
Date Signed
MM slash DD slash YYYY
