Waxing intake form
Full Name*
How did you hear about The Luminous Brow?*
Are you over 18 years old?*
Yes
No
Referred by?
Are you allergic to Latex?*
Yes
No
Are you using any of the following?*
Retin-A
Renova
Accutane (oral form of Retin-A)
None of the above
Are you currently taking any medications?*
Using any skin thinning products/medications?*
Yes
No
Are you taking any antibiotics? *
Yes
No
Any allergies? *
Are you exposed to the sun daily?*
Yes (more than 1 hour a day)
No
Any adverse reactions to previous brow tinting?*
Yes
No
Are you diabetic?
Yes
No
Are you currently pregnant ?*
Yes
No
Have you ever been treated for cancer?
Yes
No
Have you use a tanning bed in the last 72 hours?
Yes
No
Had any of the following in the last week?
Chemical peel
Botox
Laser treatment
None of the above
Anything else you need us to know?