Clone of Brow and Lash Intake Form

Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Today’s Date

MonthDayYear
How did you hear about us?
What do you consider your skin type? Please select to the best of your ability.*

NormalOilyAcne-proneDryAgingCombination (Dry and Oily areas)SensitiveRosacea
Health and Medical History*

Pregnant or TryingLess than 6 weeks PostpartumHigh Blood PressureBruise EasilyPoor Wound HealingSeizuresUsed Retin-A (or a similar medication) within the past 10 daysCurrently on my menstrual cycle OR will be within 2 daysDiabetic or diagnosed with a different autoimmune diseaseRecent Cosmetic Injectables within 2 weeks (e.g., botox, filler)Pacemaker or Metal/Electronic ImplantsRecent chemical peels/lasersRecent waxing around browsNone of the aboveOther
If relevant, please describe any of the above information checked off:
Please list any medications, supplements, or herbal remedies you currently take:
If none, simply write “none.”
Please list any skincare products you currently use that exfoliate, resurface, or contain active ingredients (e.g., retinoids, acids, scrubs, peels, AHA/BHA, enzymes).
Please list allergies or sensitivities:*
(e.g., skincare ingredients, latex, fragrances, medications) If none, simply write “none.”
All About Your Brows

(Skip if your appointment is only for a lash lift.)
Have you ever dyed or permed/laminated your eyebrows before?

YesNo
Did you experience any adverse reactions?

YesNoNot applicable
If yes, please describe:
Please list any prescribed medication for acne taken within the last 6 months:
(e.g., accutane, retinol)
All About Your Lashes

(Only answer if you’re getting a lash lift — skip if just brow services!)
Have you ever dyed or permed/lifted your lashes before?

YesNo
Did you experience any adverse reactions?

YesNoNot applicable
If yes, please describe:
Requesting Accommodations or Modifications
If you experience chronic pain (e.g., back, shoulders, neck) or have any other physical needs or limitations, please let us know how we can best support your comfort during your service.
Pre Appointment Guidelines

Lash Lifts: Arrive eye makeup-free, especially avoiding mascara. — Brow Laminations and Shaping/Waxing: Avoid retinoids, exfoliants, or chemical peels 3–5 days before your appointment. Avoid sun exposure, tanning, or heat treatments 24–48 hours before your session. — All Services: Stay hydrated.
By submitting this form, you agree to the following:
1. I give permission to receive facial, light massage, brow/lash lamination, and/or waxing services.
2. I understand that the esthetician does not diagnose illnesses or injuries, prescribe medications, or provide medical advice.
3. I have clearance from my physician to receive facial, massage, and waxing services.
4. I understand that the risks associated with massage, facials, and waxing include, but are not limited to:
  • Superficial bruising or redness
  • Short-term muscle soreness
  • Exacerbation of undiscovered injury
5. I release Cindy Perez from all liability concerning any injuries that may occur during this session.
6. I understand the importance of informing my esthetician of all medical conditions, medications, and any changes to these. I acknowledge that additional risks may exist based on my health.
7. I understand it is my responsibility to inform my esthetician of any discomfort during the session so adjustments can be made.
8. I understand that either I or the esthetician may terminate the session at any time.
9. I understand that proper aftercare is required to achieve the best results. This includes avoiding water, steam, oil-based products, or rubbing my lashes or brows for at least 24 hours after services such as tinting, lamination, or lash lifts.
10. I consent to photos or videos of my treatment for documentation or promotional use. I understand that images may be shared publicly by the esthetician.
11. I have been given the opportunity to ask questions about the session, and all my questions have been answered to my satisfaction.
Signature*
Should be Empty:

All About Your Brows

All About Your Lashes

Pre Appointment Guidelines