INTAKE FORM | BROWS

ALL INFORMATION IS CONFIDENTIAL.

Name (required)

Date (required)

Address (required)

Email (required)

Cell Phone (required)

Whom may we thank for your referral?

Please tick any of the following that apply:

Recent microblading or tattooing service.

Brow henna application.

Have you had Lash or brow tinting, lash lifting, lash perming, eyelash extension or semi-permanent mascara applied previously? 

Botox and dermal fillers.

Please check the prescription medications you are currently using:

Anti-aging creams such as Vitamin A, Retinols, AHA's and BHA's. Please list:

Are you allergic to any cosmetic ingredient, medication or food? Please list:

In the past 30 days, please list all professional facial or dermatology services you have received (i.e. Chemical Peel, Microdermabrasion, Laser, Botox, etc. (required)

 I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s). (required)