Request edit access
Permanent Solutions at The Browtique
Sign in to Google to save your progress. Learn more
Name *
Address *
Phone Number *
Email *
Emergency Contact Person and Phone Number *
Do we have permission to take photos? *
May we use the photos taken for marketing purposes? *
Do you have a history of MRSA? *
Botox? *
If YES, how long ago?
Diabetes? *
If YES, is it currently controlled?
Clear selection
Lip Fillers? *
Cold sores/Fever blisters? *
Blepharoplasty? (Plastic Surgery of the Eye) *
Hepatitis? *
Forehead or Brow Lift? *
Prone to bleeding easily? *
Face Lift? *
Alcoholism? *
Eye surgery / injury / corneal abrasion? *
Abnormal Heart Conditions? *
Currently Wearing Contacts? *
Taking medications before dental work?
Clear selection
Chemical Peel? *
If YES, when was last treatment?
MM
/
DD
/
YYYY
Currently pregnant or breastfeeding? *
Brow or Lash Tinting within the last week? *
Recently received Lash Lift OR Extensions? *
Autoimmune Disorder? *
Oily Skin? *
History of Cancer? *
Chemotherapy or radiation? *
Accutane/Acne Treatment (vitamin A derivatives)? *
Tanning (by tanning booths/bed or sun)? *
Tumors/Growths/Cysts? *
Difficulty numbing with dental work? *
Taking blood thinners (aspirin, ibuprofen, alcohol, Coumadin, etc.)? *
Allergic to ANY Medications? *
Allergic to ANY food, metals, etc? *
Any conditions or disorders not listed? *
Taking vitamins OR using skincare products containing Rein-A, glycolic or AHAs? *
Name *
Date *
MM
/
DD
/
YYYY
Clear selection
Name *
Date *
MM
/
DD
/
YYYY
Aftercare instructions have been explained and a written copy has been provided to retain in mypossession; I will follow the regimen to the best of my ability. *
Required
I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness, and bruising may occur. *
Required
I understand that Retin-A, Renova, Alpha Hydroxy Acids, Beta Hydroxy Acids, and/or Glycolic Acids must not be used in these areas; they will alter the color. *
Required
 I understand that sun, tanning beds, pools, medications, and some skincare products can affect my ​Permanent Makeup​. *
Required
 I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. *
Required
I agree to inform all skincare or medical professionals of my ​Permanent Makeup p​ rocedure(s), ESPECIALLY if I am scheduled for an MRI. *
Required
I accept full responsibility for expressing the desired color, shape, position, and size for my Permanent Makeup​ procedure. *
Required
 I understand that this procedure is designed to serve as a base and that perfect results are not guaranteed; Unforeseen challenges may arise during the 1st treatment and/or healing process- always look forward to your touch-up/revision. *
Required
I understand that implanted pigment can slightly fade or change over time due to circumstances beyond your control; the color will need to be maintained with a revision session (within 6-12 weeks of the 1st treatment) as well as with future applications. *
Required
 I acknowledge that the proposed procedure(s) involves inherent risks and complications may occur (such as infection, misplaced pigment, poor color retention, and hyper-pigmentation) during the session or during the healing process; I will follow the aftercare instructions to the best of my ability. *
Required
I have been quoted the cost of today's appointment *
Required
What was your quote for the first treatment? *
What was your quote for the second treatment? *
Your touch up appointment (2nd Treatment) can be made anytime between 6-12 weeks after first treatment
The Browtique reserves the right to charge full price for Permanent Makeup services past 12 weeks
The Browtique reserves the right to refuse a refund of deposit or for services rendered. I understand the risks involved in the procedure. I have had the opportunity to ask questions and have all of my questions answered. I acknowledge that I have reviewed and approved the material given. I acknowledge that I have answered the questionnaire truthfully and made my Permanent Makeup Artist aware of any health conditions, concerns, or previous procedures.
I herby authorize ______ as my Permanent Makeup Artist to perform the desired procedure on my body today *
Name *
Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms