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First Name*

Last Name*

Date of Birth*

Age*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Email*

Your email address will be used for appointment confirmations, quarterly newsletters, and to alert you of specials and promotions.

Occupation

How were you originally referred to Bella Via?*

If Friend/Other, who referred you?*

Area Specifics

Is this the first time that you have had a brow lamination service? If no, how long ago did you receive treatment?*

Are you planning to attend a special event (wedding, reunion, other)? If so, when?*

Please indicate if you have had any of the following treatments within the last 60 days:

Lash Tinting

Lash Lift/Perm

Eyelash Extensions

Semi-Permanent Mascara

Brow Tinting

Brow Henna

Microblading

Facial Tattooing

Do you currently have a sunburned or windburned face? If yes, please list reason.*

Do you tan via artificial tanning beds or booths? If yes, when was your last visit?*

Are you pregnant or lactating?*

Have you had facial waxing within the last 3-5 days?*

Have you shaved your face within the last 3-5 days?*

Do you have regular dermal filler injections?*

Do you have regular Botox injections?*

Are you currently using anti-acne medications such as accutane, doxycycline, or epiduogel? If yes, how long have you been using it?*

Are you currently using anti-aging creams such as Retin-A, AHA’s, or BHA’s?*

How frequently?*

Where do you apply it?*

Please check all allergies and/or sensitivities:

Aloe Vera

Ammonia

Apples

Aspirin

Citrus

Grapes

Hydroquinone

Latex

Milk

Perfumes

Other

If Other allergy and/or sensitivity*

Please list all drug allergies:*

If none, write "n/a"

Please check any of the following that apply to you:

Eczema/Psoriasis

Dermatitis

Dry Skin

Sores/Open Wounds

Ringworm

Herpes Simplex

Chicken Pox

Shingles

Conjunctivitis

Impetigo

Blepharoplasty

Rhytidectomy

Microdermabrasion

Chemical Peels

Spray Tans

Severe Illness

Flu Symptoms

Thyroid Diseases

Chemotherapy

Iron Deficiency

Alopecia

Trichotillomania

Folliculitis

Topical Steroids

Brow Growth Serums

Oral Contraceptives

Hormonal Replacement Therapy

Hypersensitive Eyes or Skin

Exposure to Chemicals in Swimming Pools, Bleach, Hair Dye, or Perms

Disease/Disorder that causes Shaking, Twitching, or Erratic Movements

Consent

Consent 1*

Do not perform Brow Lamination if any of the following contraindications exist: Alopecia, Trichotillomania, Bells Palsy, Sjogren’s Syndrome, or any disease/disorder that causes shaking and/or twitching.*

Consent 2*

I agree to get a doctors referral if I am a post Chemotherapy patient.*

Consent 3*

I understand that there are risks associated with having this procedure. I further understand that the procedure could cause swelling, redness, bumps, peeling and itchiness on or near the eyebrow and that eye irritation, eye itching, discomfort, and in rare cases, eye blurriness or infection can occur. I agree that if I experience any of these conditions, I will contact my technician and consult a physician at my own expense.*

Consent 4*

I understand that there are no guarantees as to the results of this treatment due to many variables such as age, condition of skin, climate, etc.*

Consent 5*

I understand that though my technician uses proper technique, instruments, adhesive, cleansers, and removers, my eyes may become temporarily irritated or in rare cases, require a physician’s care. I release my technician from all liability associated with the procedure, which is performed with utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use.*

Consent 6*

The treatment that I will receive has been explained to me by my esthetician.*

Consent 7*

I understand that this procedure is semi-permanent.*

Consent 8*

I understand and consent to having my eyes closed and covered for the duration of the procedure.*

Consent 9*

I understand and consent to removing contact lenses prior to the procedure.*

Consent 10*

I hereby agree to all of the above and agree to have this treatment performed on me. I further agree to follow all post-treatment care instructions as I am directed.*

I consent to having “Before” and “After” photographs of said procedure(s) for the purpose of documentation in my file.*

These photographs MAY be used anonymously on your website or in your brochure for advertising purposes.

These photographs MAY NOT be used anonymously on your website or in your brochure for advertising purposes.

Consent 11*

I certify that the above statements are true and correct, and that I, having been advised and fully informed by my esthetician of Bella Via, concerning the nature of the service proposed and hereby authorize and direct them to perform this service as may be deemed necessary or advisable. My submission of this form constitutes my acknowledgement that I have read, understand and fully agree to the foregoing. I understand the caution and contraindications for the service proposed; give consent to the proposed service that has been satisfactorily explained to me and have all the information that I desire. I hereby give my consent and authorization voluntarily and release Bella Via Skin and Body Therapies and its agents of any claims that I have or may have in the future in connection with the described application or service.*

Brow Lamination Intake Form

Area Specifics

Consent