Brows Intake Form (Lamination, Wax + Tint)

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
EmailIf you want copy of form emailed to you, please enter email here.
example@example.com
4
Cell Phone Number* This field is required.
Area Code
Phone Number
5
Do you want to be contacted via text message for future appointments?* This field is required.
YESNO
6
How did you hear about me?
Instagram
Facebook
Yelp
Google
Referral
Other
7
Please Choose Which Service You Are Scheduled For:* This field is required.
Brow Lamination
Wax & Tint
Tint
Wax
8
Please indicated if any of the following apply to you:* This field is required.
Psoriasis
Eczema
Alopecia
Sunburn
Ultra-Sensitive Skin
Wounds or Scar Tissue in the treatment area
Infection
Pimple in the treatment area
Pregnancy
Breastfeeding
Allergic to Tree Nuts
None of the Above
9
Please Indicate if Any of the Following Apply to You:* This field is required.
Used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours
Using Retin-a, Retinol or Accutane (an oral form of Retin-a) with in the past week
Using any other skin thinning products and/or drugs
Exposed to the sun on a daily basis or are you considering spending more time in the sun soon?
Use a tanning bed
Have diabeties
Allergic to Tree Nuts
None of the Above
10
Have you had any semi-permanent makeup done in the treatment area?* This field is required.
YESNO
11
How long ago was the semi-permanent makeup done?
12
Have you had any skin treatments on your face in the past 4 weeks?* This field is required.Such as chemical peels or laser resurfacing?
YESNO
13
Have you used any chemical exfoliants on the area in the past 48-72 hours?* This field is required.Such as Glycolic, Salicylic, Retinol, Lactic or other such acids?
YESNO
14
Have you been on any medication that can affect the skin (such as Accutane) in the past 6 months?* This field is required.
YESNO
15
List ALL known allergies/relevant medical conditions here:Leave blank if none
16
Terms and Conditions* This field is required.Please read and acknowledge the following agreement, and check the "I Agree" box to continue. Date and signature required on following pages.
17
Terms and Conditions* This field is required.Please read and acknowledge the following agreement, and check the “I Agreel box to continue. Date and signature required on following pages.
18
Today's Date
Date
Month
Day
Year
19
Signature* This field is required.
Clear
20
Signature* This field is required.
Should be Empty: