THE AESTHETIC SHOPPE

THE AESTHETIC SHOPPE
CLIENT & APPOINTMENT
CLIENT NAME

First NameLast Name
PREFERRED NAME

First NameLast Name
PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
APPOINTMENT DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ESTHETICIAN

First NameLast Name
BROW GOALS & SERVICE HISTORY
Brow Goals
When was your last brow wax?
Any brow tint, lamination, henna, threading, tweezing, or permanent makeup recently?
Have you reacted to waxing or another hair-removal service before?
If yes, describe:
SKIN, MEDICATION & TREATMENT SCREENING

SKIN, MEDICATION & TREATMENT SCREENING Please answer every item. A "yes" does not always prevent service; it helps your esthetician choose the safest

Rows	YES	NO
Prescription or over-the-counter retinoids, retinol, tretinoin, adapalene, or other exfoliating acne/anti-aging products on or near the brows
Oral isotretinoin (such as Accutane) or another medication that may thin, sensitize, or affect healing of the skin
Antibiotics, steroids, blood thinners, or medication that may increase skin sensitivity, bruising, or bleeding
Recent chemical peel, laser treatment, microneedling, microdermabrasion, facial, or other resurfacing treatment near the brow area
Sunburn, tanning, windburn, peeling, cuts, scabs, rash, infection, cold sore, active breakout, or broken/irritated skin near the brows
Very sensitive skin; eczema, psoriasis, rosacea, dermatitis, diabetes, impaired healing, bleeding disorder, or reduced sensation
Allergy or sensitivity to wax, resin/rosin, fragrance, latex, adhesives, skin-care products, or topical ingredients
Pregnant, nursing, or experiencing hormonal changes that may increase skin sensitivity

Please list relevant products, prescriptions, conditions, allergies, dates, or details:
Important: Tell your esthetician about any change before each appointment. If there is a concern about skin integrity, medication, or healing, the service may be modified or rescheduled. This form is not a substitute for medical advice.