Lash & Brow Intake Form

Full Name

Birthday

Month

Day

Year

Do you have any of the following conditions? (Check all that apply)

Do you have any eye conditions (infections, styes, conjunctivitis)?

Epilepsy or seizures

Have you had recent eye surgery or procedures?

Active infection (cold sores, shingles, etc.)

Do you wear contact lenses?

Skin cancer or suspicious lesions

Pregnancy or breastfeeding

Do you have any allergies or sensitivities to latex, Hair dye or tints, Perm solutions wax, rosin, fragrances or essential oils, medications, foods or skin products/ingredients?*

Do you have any skin conditions (eczema, psoriasis, dermatitis, etc.)? If yes, please specify:*

Are you currently taking any of the following?

Accutane (or isotretinoin, within last year)

Retin-A / Retinol / Tretinoin

Lash or Brow Growth Serums

Hormone therapy / birth control

Steroids (oral or topical)

Have you had any of the following in the past 2 weeks?

Chemical peel

Laser treatment

Any facial - waxing / threading / hair removal

Botox or filler

Have you had a previous lash lift/extensions or brow lamination that resulted in irritation or damage?

Yes

Are your lashes/brows currently tinted, permed, or chemically treated? (Within the last 6 weeks)

Yes

The Nest Beauty Services

TheNestBeautyServices@gmail.com

4091 Riverdale Road

Riverdale, UT 84403

bottom of page

Lash & Brow Intake Form

Lash & Brow Intake Form

The Nest Beauty Services

Follow us