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Perfact Borw Arch By Threading - www.perfactbrow.com 336-774-3094
3224 Silas Creek Parkway Winston Salem NC 27012

Please fill in all information below, after complete return device back to customer service.

Full Name *

Phone Number *

E-Mail *

Home or Mailing Address *

Emergency Contact Name & Phone *

Occupation *

Procedures Desired & Color *

Eyeborws

Eyeliner

Lip Color

Areola

Required

Do you wear contact lenses? *

Yes

Do your eyes water easily? *

Yes

Have you ever had any permanent makeup procedure? *

Yes

Other:

Ever had any off fallowing conditions? *

Diabites

Hypertension

Glaucoma

Eye Surgery or Injury

Fever blister

Currently numbing applied to skin (Dentist visit for example)

Currently take Aspirin, ibuprofen or coumadin?

Other:

Required

List all medication you are taking *

Have you ever undergone a skin peel? *

Yes

What products do you use for skin care? *

Permission to take photos? *

Yes

Do you desire an allergy test? *

Yes

Payment by: *

Cash

Check

Card

Other:

I understand that if i fail to cancel my appointment within 48 hours, there will be a $50 charge. *

Yes, I agree.

Required

Practitioner makes no attempt, or claim to practice medicine. Some individuals will have complications related to permanent makeup application. They are usually mild and last only a few days, however extreme complications are a possibility, If you are healthy and there is no visible reasons restricting you from receiving a tattoo you must approve of the design and color before the application of your permanent makeup.

WAIVER AGREEMENT

THE UNDERSIGNED acknowledges that Bhavi Patel has explained the nature of all the above –noted
treatment of permanent makeup procedures including the risks and dangers inherent therein.
I HEREBY CONSENT to Bhavi Patel performing the above-noted treatment procedures on me and in
consideration of their so doing; I hereby release and forever discharge, Perfact Brow Art by Threading,its
officers and employees of and from all claims, demands, damages, actions or causes of action arising out of the
performance of the said treatment procedures, which I, my heirs, executors, administrators or assigns can, shall,
or may have. (NO REFUND ON ANY TREATMENT.)

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