New Brow Client Intake Form
Full Name
*
First Name
Last Name
Age
Gender
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Are you currently taking any supplements, vitamins or medications (including topical and oral steroids)?
*
Yes
No
If so, please list them below
Do you have any known allergies?
*
Yes
No
If so, please list them below
Have you used or are currently taking any acne medications?
*
Yes
No
If so, approximately how long ago?
Please upload an image of your brows. Image must be taken in a well lit area with a neutral background.
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Please tell us briefly about your brow history and goals
Your appointment, your music choice! Feel free to leave a few of your favorite artists below. If you do not have a preference, please say "N/A"
By signing below, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to inform the esthetician of any changes in the above information. I agree to waive all liabilities towards my esthetician for any injury or damages incurred due to any misrepresentation of my health history.
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