Client Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Is this your first time to receive an eyebrow service?
Yes
No
What previous services have you received in the last 6-8 weeks that relate to your service?
Have you had any recent Facial Treatments (Peels, Laser, Microdermabrasion)?
Yes
No
Please give details.
Do you have sensitive skin?
Yes
No
Do you struggle with acne lesions or currently have any cuts, scrapes or damaged skin in the brow area?
Yes
No
Are you currently taking any medications that affect the skin (e.g., Steroids, Antibiotics, Blood Thinners)?
Yes
No
Please give details.
Do you have allergies to any skincare or cosmetic products (e.g., Tinting dyes, Wax, Adhesives)?
Yes
No
Please give details.
Do you currently use any of the following skincare ingredients?
Do you currently use any products containing AHA’s (Alpha Hydroxy Acids) or BHA’s (Beta Hydroxy Acids)? If NO, please skip this section.
Do you have any of the following conditions?
Allergies
Eczema/Psoriasis/Dermatitis
Rosacea
Cold Sores/Herpes Simplex
Diabetes
Lupus
Alopecia
Thyroid Disorders (Hypo/Hyperthyroidism)
Cancer
High/low blood pressure
Sunburn or Recent Sun Exposure
Hemophilia
Heart Conditions
None
Other
Check the following if any of them applies for you.
Pregnancy
Breast feeding
None
Are you under any medication?
Yes
No
Please give details.
Have you used any exfoliants on the area in the last 48 hours?
Yes
No
Have you used any self-tanning products or used a tanning bed in the last 48 hours?
Yes
No
Do you prefer a natural or bold brow look?
Select your skin type:
Normal
Dry
Oily
Sensitive
Do you experience any flaking of skin in the brow area?
Yes
No
Date
-
Month
-
Day
Year
Date
Client's Signature
*
Therapist's Signature
Continue
Continue
Should be Empty: