In Take Forms Full Name Date of Birth Phone Number Email Emergency Contact Name Emergency Contact Phone Number How did you hear about us? Are you currently under a physician’s care? Yes No If yes, please explain. Do you have food allergies (skin, food, medications, etc.)? Are you pregnant or breastfeeding? Yes No Do you have any medical conditions (diabetes, epilepsy, heart issues, autoimmune, etc.)? Are you currently taking any medications (including Accutane)? If so, please list. Are you currently taking any medications (including Accutane)? If so, please list. Do you have any contagious conditions (fungal infections, bacterial infections, active viral outbreaks)? Yes No Have you had any recent surgeries or cosmetic procedures? Yes No Have you had any recent surgeries or cosmetic procedures? Yes No Do you currently have an active cold sore (herpes simplex) outbreak? Yes No Do you frequently experience cold sores? Yes No If yes, when was your last outbreak? If yes, when was your last outbreak? How would you describe your skin? Normal Dry Oily Sensitive Acne-Prone Mature Have you ever had reactions to skincare products? Yes No If yes, please explain: Do you use retinol, AHA/BHA, benzoyl peroxide, or exfoliants? Yes No Do you use tanning beds or tan often? Yes No Have you received any cosmetic procedures (Botox, fillers, peels, laser)? Yes No If yes, when & what? Yes No Send Lash & Brow History (If Applicable) Have you had lash extensions before? Yes No Any past allergic reactions to lash glue or tint? Yes No Do you wear contact lenses? Yes No Do you tint or laminate brows/lashes? Yes No Send Waxing History (If Applicable) Have you been waxed before? Yes No Any reactions to waxing previously? Yes No Are you using retinol, tretinoin, benzoyl peroxide, or acne medications? Yes No Do you have any skin thinning conditions (eczema, psoriasis, dermatitis)? Yes No Are you currently using antibiotics or steroids? Yes No Send Lifestyle & Goals How often do you follow a skincare routine? Current skincare products you use Main skin concerns: Goals for today’s service Send Consent & Policies I understand treatments may involve the use of skincare products, tools, or machines appropriate for my skin needs. Yes I confirm the information provided is accurate to the best of my knowledge. Yes I understand that active infections, open wounds, or cold sores may prevent treatment. Yes I understand cancellations within 24 hours may be subject to fees. Yes Full Name I agree everything above is true. Yes Todays Date Send
