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Brow/Face Intake

Client Information

First name*

Last name*

Email*

Phone

Which of the following services have you had done in the PAST?*

Brow Hair Removal

Brow Tinting

Facial Hair Removal

Facial

Botox/Filler

Dermaplaning

Chemical Peel

Microneedling

Laser Hair Removal

Laser Skin Resurfacing

Other Advanced Modality

How did that experience go?

Services to be Provided

Which of the following services do you consent to having done at FFBC?*

Brow and/or Facial Hair Removal

Brow Tinting

Brow Lamination

Facial

Dermaplaning

Chemical Peel

Microneedling

Other Advanced Modality

Please note, you may be a better candidate for one method over another depending on any contraindications. We will discuss those options in person. You will be asked to fill out the form again if we decide to perform a service that you have not consented to on this form.

Health History

If you are currently under a Physician's care, describe what for:

If you are currently under a Dermatologist's care, describe what for:

Do you have any of the following medical conditions? (please check all that apply)*

Cancer

Herpes

HIV / AIDS

Seizure Disorder

Any Active Infection

Thyroid Imbalance

Rosacea

Diabetes

Arthritis

Keloid Scarring

Hepatitis

Blood Clotting Abnormalities

Skin Cancer

High Blood Pressure

Frequent Cold Sores

Skin Disease / Skin Lesions

Hormone Imbalance

None

Other

If yes, please explain.

Have you had any surgery where lymph nodes were removed?*

Yes

Do you have any other health problems or medical conditions? Please list:

Are you currently pregnant or breastfeeding?*

Yes

Hormonal changes can affect skin sensitivity.

If yes, please explain how far along.

Are you taking any medications or herbal supplements (oral or topical)?*

Yes

Especially antibiotics, blood thinners, or steroids.

If yes, please explain.

Are you currently taking ANY acne medications or taken them in the past?*

Yes

If yes, please specify what kind, how long you were on it, and when you stopped taking it:

Have you had a skin cancer diagnosis at any point?*

Yes

If yes, when, where on the body, and what was the result?

Do you have any allergies that you're aware of?*

Yes

Especially to products/ingredients, food, latex, citrus, nuts, aspirin, lidocaine, Hydrocortisone, Hydroquinone or skin bleaching agents, etc...

List of known allergies and the reactions that happen:

Please notify your esthetician of any allergies prior to your service.

Lifestyle & Skin

Have you ever had Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

Yes

If yes, please describe.

Do you use Retin-A, Renova, or Retinol/Vitamin A derivative products?*

Yes

If yes, how often?

Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hours?*

Yes

Unsure

Have you had recent surgeries or cosmetic procedures (chemical peels, fillers, Botox, laser treatments)?*

Yes

Especially within the past 2–4 weeks.

If yes, please list what kind and when.

Do you have any existing skin conditions or concerns?*

Yes

If yes, please list describe

Check all that apply:*

uses saunas

exercises

sweats excessively

oily skin

dry skin

normal skin

combination skin

acne or acne prone

exfoliate regularly

sensitive/reactive skin

textured skin

redness in skin

excessive hair growth

ingrown prone

smoke cigs/cannabis

other/none

Describe any skin concerns or goals here:*

Which of the following best describes your skin type? (please check one)*

Creamy complexion: Always burns, never tans

Light complexion: Always burns, sometimes tans

Light/Tan complexion: Sometimes burns, always tans

Tan complexion: Rarely burns, always tans

Brown complexion: Rarely burns, deep tan

Black complexion: Never burns, deeply pigmented

What kind of climate do you live in?*

Occupation*

Hobbies/Activities*

Have you experienced breakouts, rashes, or irritation from facial products or hair removal in the past?*

Yes

Sometimes

Is skincare important to you?*

Yes

Sometimes

Do you wear makeup on a daily/regular basis?*

Yes

Sometimes

Do you spend a lot of time in the sun or use tanning beds?*

Yes

Sometimes

Do you wear SPF daily?*

Yes

Sometimes

Do you drink enough water daily?*

Yes

Sometimes

Do you smoke or consume alcohol frequently?*

Yes

Sometimes

These can affect skin healing and appearance.

Are you planning any special events or travel soon?*

Yes

Sometimes

Post-treatment care is important; skin may be red or sensitive for a day or two.

Procedure Understanding and Consent

I, the undersigned, request and consent to the application of waxing, sugaring, tinting, lamination, facial / body treatments, and advanced modalities to my eyebrows and/or facial areas by the trained technicians/Estheticians of Fearless Femme Beauty Company.

I understand that the procedure(s) involve the application of wax, sugar, tint, and/or perming chemicals, or various skincare products and sharp implements to the specified areas and that there are inherent risks, including but not limited to skin irritation, allergic reactions, and discomfort.

I acknowledge that rare side effects may occur, and I agree to consult a physician if any adverse reactions persist.

I agree to follow any aftercare instructions provided by Fearless Femme Beauty Company to ensure optimal results and minimize potential risks.

I consent to the use of photographs or videos taken during my service for promotional purposes, understanding that my identity will remain confidential unless otherwise agreed upon.

Client Acknowledgment

I have provided accurate and complete information regarding my health, allergies, medications, and skin conditions. I understand that withholding information may result in adverse reactions.
I agree to inform my esthetician of any changes to my health status or skin conditions prior to each service.
I understand that Fearless Femme Beauty Company reserves the right to refuse service to anyone exhibiting contraindications or not adhering to health and safety protocols.

Liability Waiver

By signing this agreement, I acknowledge the inherent risks associated with the services provided, including but not limited to allergic reactions, skin irritation, or other adverse effects, and voluntarily assume full responsibility for any injury, damage, or loss that may result. I hereby waive, release, and hold harmless Fearless Femme Beauty Company, its owners, employees, and contractors from any and all liability, claims, actions, or demands, past, present, or future, arising from or related to the services provided.

Signature*

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Date*

Month

Day

Year

Brow/Face Intake

Client Information

Services to be Provided

Health History

Lifestyle & Skin

Procedure Understanding and Consent

Client Acknowledgment

Liability Waiver

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