Brow Lamination Intake Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone#
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Emergency Contact Name
Phone#
Format: (000) 000-0000.
How did you hear about us?
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Health & Skin Screening
Have you ever had an allergic or adverse reaction to brow lamination, brow tint, hair dye, henna, waxing, perming solutions, or similar products?
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Yes
No
Do you have any known allergies or sensitivities to tint, hair dye, peroxide/developer, perming solutions, wax, latex, adhesives, or cosmetic ingredients?
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Yes
No
Do you currently have redness, irritation, swelling, broken skin, cuts, rash, sunburn, dermatitis, eczema, psoriasis, infection, or another skin condition in or around the brow area?
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Yes
No
Are you currently using Retin-A/tretinoin, retinol, retinal, adapalene, tazarotene, or another topical retinoid on or near the brow area?
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Yes
No
Are you currently taking, or have you recently taken, Accutane/isotretinoin?
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Yes
No
If yes, when was your last dose?
Have you recently used AHA/BHA acids, glycolic acid, salicylic acid, exfoliating products, scrubs, or other strong active skincare products around the brow area?
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Yes
No
Have you recently had a chemical peel, laser treatment, microneedling, dermaplaning, microdermabrasion, or other resurfacing treatment around the brow area?
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Yes
No
Have you recently had Botox, filler, permanent makeup, microblading, powder brows, or another cosmetic procedure around the brow area?
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Yes
No
If yes, when?
Are you using any medication or topical product that causes skin thinning, peeling, increased sensitivity, or delayed healing?
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Yes
No
Have you ever experienced skin lifting, tearing, bruising, excessive irritation, or another significant reaction from waxing?
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Yes
No
Have you ever experienced burning, swelling, itching, blistering, or another reaction following brow lamination, tinting, hair coloring, or waxing?
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Yes
No
Are your brow hairs currently very dry, brittle, damaged, breaking, or noticeably thinning/shedding?
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Yes
No
Have you had brow lamination or another chemical treatment on your brow hairs within the last 6–8 weeks?
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Yes
No
Have you had a patch test with the lamination and/or tint products being used?
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Yes
No
If yes, when?
Is there anything else regarding your skin, allergies, medications, health, previous reactions, or recent treatments that your esthetician should know before performing your service?
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Brow Lamination Consent Form
I acknowledge:
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I understand that brow lamination chemically alters the structure and direction of my natural brow hairs, and that repeated or excessive chemical processing can result in dryness, brittleness, frizzing, overprocessing, or hair breakage.
I understand that brow tinting uses chemical coloring products and may cause irritation, redness, itching, swelling, sensitivity, allergic reaction, or temporary staining of the surrounding skin.
I understand that waxing removes hair from the follicle and may temporarily remove or irritate the superficial layers of skin, causing redness, tenderness, swelling, bruising, follicular irritation, skin lifting, or other irritation. Certain medications, skincare ingredients, exfoliation, cosmetic treatments, and sun exposure may increase these risks.
I understand that an allergic reaction or sensitivity may occur even if I have previously received these services or used similar products without a reaction, and that a patch test cannot guarantee that a reaction will not occur.
I understand that results vary based on my natural brow hair, growth pattern, hair condition, skin type, previous treatments, and home care. Exact shape, fullness, color, symmetry, longevity, and overall results cannot be guaranteed.
I agree to immediately inform my esthetician if I experience burning, stinging, itching, pain, or significant discomfortat any point during the service.
I confirm that I have disclosed relevant medications, skincare products, allergies, sensitivities, skin conditions, previous reactions, and recent treatments. I understand that my esthetician may modify, postpone, discontinue, or refuse any portion of the service if my skin or brow hairs appear compromised.
I agree to follow the recommended aftercare instructions and voluntarily consent to receiving Brow Lamination, Waxing & Tinting.
By signing below, I acknowledge there is a no-refund policy in place. By paying for my service at the completion, I am acknowledging that I am satisfied with my services provided and credit card disputes will then be considered frivolous.
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
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Take Photo
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Name Printed
*
Signature
*
Submit
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