FORM 1

MEDICAL HISTORY

MEDICAL HISTORY FORM

Full Name *

Date of birth *

Phone *

Email *

Street Address *

City *

State *

Postal code *

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MEDICAL HISTORY FORM

By signature below, I hereby acknowledge that: (i) I am at least 18 years of age; (ii) I have read and understood the above questions and have been afforded an opportunity to ask questions about any of the information requested in this medical history form; and (iii) all medical histories and other information provided by me to Brow Theory Inc is complete and accurate.

I hereby consent to share the medical history information within this form with Brow Theory Inc. I understand this information will be stored electronically using softare and servers that are not directly owned or controlled by Brow Theory Inc. I acknowledge that third-party service providers may have access to the information for purposes of maintaining and supporting the software and services. I understand that while Brow Theory Inc. and its third-party service providers will make all reasonable efforts to protect my information, they cannot guarantee absolute security against data breaches or unauthorized access. I agree not to hold Brow Theory Inc. liable for any events outside their control which may lead to my medical information being unintentionally accessed or shared.

The information contained within this form will be treated as confidential and will not be shared with any individuals or third parties outside of Brow Theory Inc. and its service provider which stores the electronic file without my express written consent, except as required by law.

Today's Date *

Client Signature *

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By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. *

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