Full name
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First Name
Last Name
Which service(s) brings you to Marveleyes Brow Bar?
Nano Shaded Brows
Ombré Brows
Combo Brows
Henna Brows
Brow Lamination
Brow Tint
Patch Test
Consultation
Touch-Up
Brow Colour Correction
Are you 18 years of age or older?
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Yes
No
Date of Birth
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-
Month
-
Day
Year
Date
Current Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Are you in general good health?
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Yes
No
Have you had any previous permanent make up tattoo procedures done? If yes, please state how long ago.
Example. 3 months ago
Please check all that applies
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Allergies to Latex Gloves
AIDS or HIV Positive
Autoimmune disorder(s)
Diabetic
Undergoing chemotherapy
Currently have a viral infection and/or disease
Feeling sick (symptoms of cold, flu, feverish, etc.)
Epilepsy
Have pacemaker or heart conditions
Had an organ transplant
Pregnant or breast feeding
Had Botox within 1 month
Received an invasive facial within 1 month
On Accutane within the last year
Have history of keloid scarring
Have severe allergies to nuts (can be intolerant to Lidocane numbing cream)
Have skin irritations (rashes, sunburn, acne and etc.) near treatment area
Allergies to Lidocane
Allergies to Nickel
Have Psoriasis near treatment area
Currently under the influence of alcohol and/or drugs
Have high blood pressure
Taking blood thinners
Taking anticoagulants
Taking Aspirin
Taking Ibuprofen
Taking Coumadin
Using Retina A, Hydroxyl (Glycolic) Acid
Other
Please state whether you have any serious medical conditions not mentioned above? If so, please state it below.
Do you have any allergies not mentioned above?
Are you on any medications not mentioned above ?
Do we need a physician note? (Physicians notes must be on their letterhead or prescription pad)
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Yes
No
Are there other ares of concerns not mentioned?
Signature
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