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Intake Form
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Home
Services
Artist; about me
Gallery
FAQs
Contact us
Contact us
Intake Form
Book
Intake Form
Date
(Required)
Month
Day
Year
First and Last Name
(Required)
Cell
Email
(Required)
Service name
(Required)
Powder Brows
Waiver, Release and Consent
Please type initials here to confirm you have read and agree. I am over the age of 18 and I am not under any influence of drugs or alcohol. I am not pregnant or nursing.
(Required)
Please type initials below to confirm you have read and agree. I have been candid in revealing any condition in my client intake form that could prohibit or alter my treatment such as, but not limited to, recent surgeries, sun exposure/tanning, cold sores, tendency of scarring, used Accutane in the past 2 years.
(Required)
Please type initials below here to confirm you have read and agree. I accept the responsibility for determining the colour, shape and position of the brows as agreed to during the consultation. I understand that non toxic pigments are used during the procedure and that the results achieved may fade over a period of 2-3 years depending on skin type and aftercare.
(Required)
Please type initials below to confirm you have read and agree. I understand that pigment can remain in the skin indefinitely.
(Required)
Please type initials below to confirm you have read and agree. Upon completion of the treatment, I understand that my skin may be a little red, irritated or swollen.
(Required)
Please type initials below to confirm you have read and agree. I have been advised that the true colour of the pigment will be seen 1 month after each procedure and that the pigment may vary according to skin tone, skin type and skin condition. I understand that some skin types accept pigment more readily and no guarantee is made by the Studio or artist, Rosemarie Love.
(Required)
Please type initials below to confirm you have read and agree. To my knowledge, I do not have any physical, mental or medical impairment that might affect my well being as a direct/indirect result of my decision to have the procedure done at this time.
(Required)
Please type initials below to confirm you have read and agree. I agree to follow the post procedure aftercare instructions as provided and explained by my artist, Rosemarie Love.
(Required)
Please type initials below to confirm you have read and agree. If I am unhappy or unsatisfied with my appointment, I will not speak slander about Rosemarie Love on any online/social media platform including Google, Facebook, X, Snapchat, Instagram, Yelp etc. I will contact Rosemarie Love to allow her to work with me to find a reasonable solution, if any.
(Required)
Please type initials below to confirm you have read and agree. I hereby consent to, and authorize the use of photography and video. Photos taken during the procedure can be used on Rosemarie Love's portfolio page. I understand I am not entitled to compensation for these photos being used.
(Required)
Client Medical Information
Do you have any allergies (e.g., latex gloves)?
(Required)
Yes
No
Are you allergic to anesthetics?
(Required)
Yes
No
Are you allergic to antibiotics?
(Required)
Yes
No
Have you recently had eye surgery in the past 2 years?
(Required)
Yes
No
Do you have any tattoos?
(Required)
Yes
No
Are you currently pregnant or breastfeeding?
(Required)
Yes
No
Do you have a history of keloid scarring?
(Required)
Yes
No
If YES to keloid scarring, please specify (optional)
Do you suffer from any serious medical conditions?
(Required)
Yes
No
If YES to serious medical conditions, please specify (optional)
Do you have a skin condition (Rosacea or Eczema)?
(Required)
Yes
No
If YES to skin condition, please specify (optional)
Do you suffer from a thyroid condition? (Graves, Hashimoto, nodules etc.)
(Required)
Yes
No
If YES to thyroid condition, please specify (optional)
Are you diabetic?
(Required)
Yes
No
Have you ever taken Accutane for skin treatment either currently or in the past?
(Required)
Yes
No
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