Brow Wax & Tint 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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Brow Tint Safety Screening
Have you ever had an allergic or adverse reaction to eyebrow tint, hair dye, henna, lash tint, or similar coloring products?
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Yes
No
Do you have known allergies or sensitivities to hair dyes, pigments, peroxide/developer, PPD, resorcinol, fragrances, preservatives, or cosmetic ingredients?
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Yes
No
Have you experienced itching, burning, swelling, blistering, or redness after a previous brow or hair-color service?
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Yes
No
Do you currently have irritated, inflamed, broken, or infected skin in the brow area?
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Yes
No
Have you had a patch test for the tint product being used?
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Yes
No
Have you previously received this same tint product without a reaction? Yes / No
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Yes
No
Is there anything else regarding your skin, allergies, medications, or previous reactions that your esthetician should know before performing today's service?
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Yes
No
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Brow Wax Safety Screening
Are you currently using prescription retinoids, such as tretinoin/Retin-A, adapalene, or tazarotene, on or near the brow area?
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Yes
No
Have you used Accutane/isotretinoin recently?
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Yes
No
If yes, when was your last dose?
Have you used retinol, retinal, AHAs, BHAs, glycolic acid, salicylic acid, exfoliating acids, scrubs, or other strong exfoliating products around the brow area within the last 5–7 days?
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Yes
No
Have you had a chemical peel, laser treatment, microneedling, dermaplaning, microdermabrasion, or other resurfacing treatment near the brow area recently?
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Yes
No
Have you had Botox, filler, permanent makeup, microblading, or other cosmetic procedures around the brows recently?
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Yes
No
If yes, when?
Are you currently using any medication or topical product that causes skin thinning, increased sensitivity, or delayed healing?
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Yes
No
Do you currently have sunburn, broken skin, cuts, abrasions, rash, dermatitis, eczema, psoriasis, infection, cold sores, or significant irritation around the brow area?
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Yes
No
Have you ever experienced skin lifting, tearing, bruising, or an unusual reaction from waxing?
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Yes
No
Do you have diabetes, a bleeding disorder, impaired healing, or another condition that may affect your skin's response to waxing?
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Yes
No
Do you have any abrasions, moles, or skin irritations in the areas being waxed today?
*
Yes
No
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Client Acknowledgements
I acknowledge:
I understand that waxing may temporarily cause redness, tenderness, irritation, swelling, bruising, follicular irritation, breakouts, or skin lifting.
I understand that brow tinting carries a risk of irritation, allergic reaction, itching, redness, swelling, staining of the surrounding skin, or an unexpected color result.
I understand that an allergy or sensitivity can develop even if I have previously used the product without a reaction.
I understand that a patch test reduces risk but cannot guarantee that an allergic reaction will not occur.
I understand that tint results vary based on my natural brow color, hair porosity, skin type, previous treatments, and home-care products.
I understand that tint may temporarily stain the skin beneath or around the brow hairs.
I understand that exact brow symmetry cannot be guaranteed because facial features and natural brow growth are not perfectly symmetrical.
I authorize my esthetician to modify or discontinue the service if my skin shows signs of excessive sensitivity or irritation.
I confirm that I have disclosed relevant medications, topical products, allergies, skin conditions, and recent cosmetic treatments.
I have had the opportunity to ask questions and voluntarily consent to the brow wax and tint service.
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
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Signature
*
Submit
Geolocation
*
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