BELLA BAR POWDER BROW Intake Form
Sign in to Google to save your progress. Learn more
Email *
I will complete this Intake Release Form truthfully.  I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.  

I understand that withholding information or providing misinformation may result in contraindications and/or irritation to my skin from treatments received.  

The treatments I receive are voluntary and I release Nichole Hines, BELLA BAR, and it's representatives from liability and assume full responsibility thereof.  

Sign first and last name below:
 *
How did you find BELLA BAR?

Google, Yelp, IG, FB, Referral, Other...
 *
First and Last Name *
Phone *
Email *
Address *
Are you pregnant? *
How old are you? *
I acknowledge Powder Brows are a permanent tattoo that fades over time. *
Have you ever had any of the following conditions? Please check all that apply. *
Required
I understand that certain health conditions will required a release from my doctor for services to be rendered. I agree to submit documentation at least 7 days prior to my appointment. *
Do you agree to avoid direct sun for 24-48 hours after my skin care service. *
Have you had professional cosmetic tattooing before? 

This includes any and all permanent makeup such as eyebrows, eyeliner, and Microblading.

It is very important to answer this question honestly.

If yes, please specify.
 *
Are you taking any medications? 

This includes over-the-counter  medications.

If yes, please specify.
 *
Are you undergoing any hormone therapies or taking any infertility medications? 

If yes, please explain.
 *
Do you use any of the following?  If yes, please check. *
Required
Have you ever had an allergic reaction to your skin? If yes, mark all that apply: *
Required
Have you had any skin care treatments in the last 30 days, such as peels, microdermabrasion, at-home-remedies of any kind, etc., please specify.  

If none, type 'N/A'.  If yes, please specify:
 *
Do you have any special skin problems or concerns pertaining to your face or body? 

If yes, please specify:
 *
BELLA BAR has permission to contact me via email and text.
 *
Please take the time to read 'Required Policies and Agreements' which can be found on BELLABAR365.COM.

I have thoroughly read BELLA BAR's 'Required Policies & Agreements' and agree to comply with and will adhere to them.
 *
I acknowledge and consent that my Medical History information may be subject to further consultation with a Doctor or Pharmacist with the understanding that no client identifying information will be shared.
 *
I agree that I will not show up to my appointment sick or still showing ANY signs of symptoms from any previous illness such as the cold, flu, sinus infection,  despite thinking it is contagious or not.  

*Clients who present ill will be required to reschedule their appointment and charged the necessary booking fees.
 *
I have completed this Release Form truthfully and I have read the clause above.  

INITAL HERE.
 *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Bella Bar. Report Abuse
Google Forms