New Customer Form Name * First Name Last Name Email * Phone * (###) ### #### Gender * Female Male Other/Prefer not to say Date of Birth * MM DD YYYY Emergency Contact * First Name Last Name Emergency contact Phone Number * (###) ### #### Are you: * Pregnant Breastfeeding N/A Please select all that apply to you: * Diabetes Heart Conditions Skin conditions (eczema, psoriasis, rosacea) Epilepsy Asthma Blood-borne viruses (e.g. Hepatitis, HIV) Autoimmune conditions Recent surgery or cosmetic procedures Please list any medication you are on * Do you have any health concerns or conditions? * Treatment Information Please complete this form honestly and to the best of your knowledge. All information will be kept strictly confidential. What treatments are you interested in? * Facial Treatments Skin Boosters Waxing Brow Treatments Lash Treatments Have you had these treatments before? * * Yes No If yes, please specify: Are you currently using any active skincare (e.g. retinol, AHA/BHA, Accutane)? * Yes No If yes, please specify: Do you have any sensitivities or reactions to skincare or waxing in the past? * Yes No If yes, please specify: For Lash/Brow Services Only Do you wear contact lenses? * Yes No N/A Have you had any eye infections in the past 6 weeks? * Yes No N/A Have you had an allergic reaction to lash glue or tint before? * Yes No N/A Consent & Agreement * I confirm that the information provided is true and accurate to the best of my knowledge. I understand that it is my responsibility to inform my therapist of any changes to my health. I understand there may be risks associated with certain beauty treatments, including skin sensitivity or allergic reactions. I agree to have photos taken for record-keeping (with consent for promotional use if agreed separately). I understand that results vary and multiple sessions may be recommended for best outcomes. Thank you. Your From has been submitted.