Brow & Lash Service Intake Form
Name
*
First Name
Last Name
What is your preferred pronoun?
Please Select
She / Her / Hers
He / Him / His
They / Them / Theirs
Other
If Other, please specify
Phone Number
*
Email Address
*
Date of Birth
*
MM/DD/YYYY
How did you hear about us?
*
Facebook Ad
Instagram Ad
TikTok
Google Ad
ReferralType option 5
Radio Ad
Mailer
Google AI/ChatGPT
Your Health
List any medications, supplements, vitamins, diuretics, Isotretinoin, etc. that you take regularly:
*
Do you wear contact lenses?
*
Please Select
Yes
No
Do you have any allergies? Latex, nickel, etc.
*
Please Select
Yes
No
If yes, please specify
Have you ever had a reaction to any previous dyes or tints either in your brows or hair?
*
Yes
No
If yes, please specify.
Have you waxed in the last 3 days?
*
Please Select
Yes
No
Do you use Retin-A, Renova, Adapalene, or any other prescription skin products in the last three months?
*
Please Select
Yes
No
Have you taken isotretinoin (Accutane) within the last 6-12 months?
*
Please Select
Yes
No
Are you currently using any products that contain the following ingredients? Select all that apply.
*
Glycolic Acid
Lactic Acid
Exfoliating Scrub
Vitamin A
Other Acid ingredient
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I also acknowledge that in order to keep record of my treatment progress photo records are necessary. My esthetician has authorization to take these photos for progress tracking. These photos may be used in social media, website, or print and my identity can be protected upon request. By signing this I acknowledge and agree to all terms.
*
I agree
I do not hold my esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.
*
I agree
I agree that I will have my esthetician perform a patch test prior to my tinting or henna appointment (if applicable). Should I choose to move forward without a patch test, I will not hold my esthetician responsible for any allergies or sensitivities (although very rare) that may arise.
*
I agree
I confirm that I am not infected with COVID-19 and I am not presenting any of the following systems: fever, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat. Additionally, I confirm that I haven't been around anyone exhibiting these symptom within the past 14 days. I also confirm that I will not hold anyone responsible should I start to exhibit symptoms after my appointment.
*
I agree
I have read and agreed to Crystal Ngozi Beauty & Esthetic's policies: https://crystalngozibeauty.com/policies/
*
I agree
OPTIONAL Addendum: I do not wish to have my photos used on social media for any purpose.
I agree
Add any additional notes here:
Signature
*
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