Esthetics Intake Form

Appointment Submission Form

Please provide your personal information below. Thank you!
Hello!

Please ensure that you are reading through this form carefully so you are aware of my process and what info I need to pre screen before we can book an appointment.

Should you be a good candidate for this service, my email response to the submission form will include your appointment date and time, and answers to the questions you may list below. *I do my best to respond within 24 hrs. Please check your spam folders.

*For the eyebrows, I only offer Powder Brows (not Microblading).

My signature ShadingBlending® technique is a soft shading method done with a machine. Always a custom design and custom color selection to fit your facial features and style.

The effects result in a natural, soft powdered in look which can be subtle or defined as desired.

Minimal pain, results may last 1-3 years and touch ups will be needed if you'd like to maintain the color. Initial appointments typically take about 2-3 hrs.
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option
First Name*
Please type first name.
Last Name*
Please type last name.
D.O.B. (MM/DD/YYYY)*
Phone*
Email Address*
example@example.com
Occupation
How did you hear about us?
Referral, Instagram, TikTok, Email, etc.
Please check all the apply.*

PregnantsNursingUsing or have used prescription topical (Acne, Retin-A, Steroid creams, etc.)Prescription oral medicationSkin or health issues (Acne, Rosacea, Ezcema, Auto immune, etc)Had previous brow work done in the pastNone of the aboveOther
Pre screening photos are required to help me determine if you're a good candidate for permanent makeup services. Please include a CLEAR, FULL FACE, UNFILTERED photo in natural lighting with no makeup on.

(I'm evaluating skin & brow textures, current skin condition, structure of your brows/eyes, face, etc.)

*For brow service include a photo with makeup on the brows if you normally fill them in.
Take Photo
Upload photo 1: Full face no make-up.
Upload photo 2: With make-up.
* If there are any important details you would like me to know please write them below.
Additional details:
Esthetics Information
What type of skin do you have?*

NormalOilyDryCombination
Have you ever had an allergic reaction to any of the following?

CosmeticsMedicineTopical AnastheticsFoodAnimalsSunscreenDrugsPollenAHAsFragranceLatex
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, or Retinol/Vitamin A derivative products?*

YESNO
If yes, please describe...
Have you received Botox, Restylane, or Collagen injections in the last 6 months?*

YESNO
If yes, please specify...
Next Step: Booking
If you're looking for the next available opening please leave that in the details.

A waiting list is available for last minute openings to those that are pre booked with a deposit.

50% non refundable booking fee is required at the time of booking.
Preferred Date 1:

MonthDayYear
Date
Preferred Date 2:

MonthDayYear
Date
Preferred Date 3:

MonthDayYear
Date
Inquires and additional comments.
Will you be traveling from out of town for this appointment?

YesNo
Have you been worked on by me in the past.

YesNo
Current pricing:

Consultation - $100 (if you'd like to schedule one before or separately from the initial session) credited towards the cost of service.

Powder Brows - $550 initial session

"Basic" Touch up session (within 8-weeks of initial service only) - $250
Should be Empty:

Appointment Submission Form

Esthetics Information

Next Step: Booking