Intake & Medical History Form

INTAKE FORM

Please answer this form as accurately as possible. Your information will never be shared. These questions are just to be sure that any procedure offered here at Designer Brows is safe for you.

First Name

Email Address

Today's Date

Last Name

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Front of State Issued ID

Back of State Issued ID

I understand that my personal or medical information will never be shared. This information is to ensure that this procedure is safe for me and my artist.

By selecting this box, I certify that I have answered all health questions honestly.

Micropigmentation is the process of implanting micro pockets of pigment into the epidermis and upper dermal layer of the skin. This is a form of tattooing used for permanent cosmetics. I voluntarily request my intradermal technician to perform the following procedures:

I Understand that there may be known and unknown risks and hazards related to the performance of the planned procedure and I understand that no warranty or guarantees have been made as to the results.

I Understand that photographs of the work performed to be taken both before and after treatment, and that said photographs may be used for purposes of advertising and/or training purposes. I may request full face photos to be approved before posting.

I acknowledge that I am over the age of 18 years old.

Are you under the care of a physician? If yes, please state the medical treatments, medications, and procedures you are being treated for or have in the past. Please also list your Physician's Name and Phone Number. We must have this information to make sure any conditions will not affect the healing of your tattoo, or if it involves possible allergies to dye, pigment, or numbing agents.

Yes

Physician’s Name

Physician’s Phone

Physician’s Address

I understand that a second and on very rare occasions a third touchup procedure will be needed. As little as 20% of the pigment may remain after healing. Pigment will need to be re-implanted for a fully finished look. I also understand that annual touchups may also be needed.

I understand other risks involved may include, but are not limited to: allergic and other reactions to products applied during and after the procedure, skin irritation, swelling, and discomfort. When reactions occur, they are generally from numbing products, pigment, or aftercare ointments. I understand opting for numbing cream increases the change of a reaction, and will notify my technician if I do not want it used. I understand a test patch is recommended by most manufacturers.

I acknowledge the manufacturers of the pigment and numbing agents require spot testing and specifically disclaims any responsibility for adverse reaction to applied products. I understand spot testing may identify individuals who develop immediate allergic reactions, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I have been told that this procedure may involve discomfort. I also understand that I can ask for more additional numbing as needed, but that the more numbing that is applied, the higher the risk of having an adverse reaction.

I accept full responsibility for any and all, present and future, medical treatments and expenses I may incur in the event I need to seek treatments for any known or unknown reason associated with this procedure.

I have been given an opportunity to ask questions about the procedures to be done and the risks and hazards involved, and I believe that I have sufficient information to give informed consent.

Upon booking any new appointment, a non- refundable Booking Fee is charged to secure your appointment. The fee will be deducted from the total cost of your initial procedure; the remaining balance will be due on your appointment day. Your booking fee is non refundable, non transferable, and can only be applied to the scheduled service for the date and time secured. Please be sure about your appointment day and time before booking.

We strive to provide excellent care to you and the rest of our clients. Your care and treatment is a priority for us. We also ask that you respect your specialist's time and expertise as well. In an attempt to be consistent with this, we have a Cancellation & Late Policy that allows us to schedule appointments for our clients, with respect for your time, the next client's time, and the specialist's time.

If you need to reschedule, please notify me at 512-839-7098 via text message a minimum of 48 hours prior to your appointment date. If you reschedule after the 48 hour time frame, you will be responsible for Late Reschedule fee of $100. If you are unable to make your appointment, you MUST give a 48 hour notice to avoid a $100 Reschedule Fee. The Reschedule Fee is not deducted from the remaining balance of the procedure.

If you are more than 15 minutes late please call me at 512-839-7098. If I have a client after you then we will need to reschedule and you will be responsible for a $100 Reschedule Fee. The Reschedule Fee is not deducted from the remaining balance of the procedure.

I fully understand the Booking Fee and Cancellation Fee Policy, and hereby forfeit my Booking Fee to secure my appointment spot. There are No Refunds of any kind.

CC Number

Cvv Number

Name on Card

EXP. Date

Billing Zip Code

I have read and understand the Appointment Cancellation & Late Policy, and I agree to be bound by its terms. I am aware that my credit card will be charged for the missed appointment, and I agree to this terms.

Any Additional Information:

Full Name

Todays Date

I declare that the info I’ve provided is accurate & complete

Your Signature

Thanks for submitting!

INTAKE FORM

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