Brow Shaping Consultation Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Where did you hear about us?* This field is required.
Google
Yelp
Instagram
Referral
Other
5
Do you use/take any of the following?* This field is required.
Retinoids(Retin-A, tretinoin, Differin, over-the-counter retinols, etc.)
Salicylic Acid/Benzoyl Peroxide/Glycolic Acid
Accutane or other prescription acne medication
Antibiotics
Blood Thinners
N/A
6
If YES to the above, what is the name of the product/medication and when is the last time you used it?* This field is required.
7
Do you have any of the following?* This field is required.
Open skin lesions in the brow area
Very dry or sensitive facial skin
Eczema or psoriasis in the brow area
Sunburn in the past 2 weeks
History of skin lifting after brow wax
History of breakouts after waxing
N/A
8
Please list any medications or supplements you are currently taking.* This field is required.
9
If you are receiving a Brow Tint today, have you ever had an allergic reaction to tint or hair dye?* This field is required.
Yes
No
N/A
10
Please list any allergies or sensitivities.* This field is required.
11
Your esthetician will review your consultation form and let you know if waxing is contraindicated. Depending on your replies to the above questions, a tweeze-only shaping may be necessary.

I have read the above information and have answered all questions to the best of my knowledge. I give permission to my esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: no peels, tanning, sweating; no swimming/spas/hot tubs for 48 hours after waxing; no exfoliation or active ingredients for 72 hours. I understand that I should not touch my freshly waxed skin and that it is important to sanitize my phone/anything else that touches my face, and use a clean pillow case to prevent folliculitis. Please note that waxing can have side effects such as skin lifting, redness, swelling, tenderness, etc. I understand that my esthetician will take every precaution to minimize or eliminate negative reactions.
12
Signature* This field is required.
Clear
13
Date* This field is required.
Should be Empty: