Medical History
Please take a moment to answer this form as accurately as possible to communicate all past and existing medical conditions.
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your skin type?
*
Dry
Normal
Oily
Combination
Do you have any blood borne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis (A,B,C,D) ?
*
Yes
No
Are you currently pregnant or breastfeeding? If yes, you must not be pregnant or nursing at the time of appointment.
*
Yes
No
Have you had Botox within the past 6 months in the brow/forehead area?
*
Yes
No
Have you had any surgeries including blepharoplasty (eyelid surgery) and/or forehead/brow lift?
*
Yes
No
Allergic reaction to any medications such as Lidocaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.
*
Yes
No
Are you currently on any blood-thinning prescription drugs?
*
Yes
No
Please check all that applies to you:
Abnormal Heart Condition
Hemophilia
High Blood Pressure
Circulatory Problems
Epilepsy
Thyroid Disturbances
Cancer
Seizures
Alopecia
Watery Eyes
Keloid Scars
Anemia
Low Blood Pressure
Diabetes
Suffer from Eye Infections
Autoimmune Conditions
Other Tattoos
Bruise of Bleed Easily
Allergy to Latex/Metals/ Antibiotics
Accutane/Prescription Acne Medicine within last 12 months
Eczema (face)
Psoriasis (face)
Herpes
Sensitivity to Cosmetics
None of the above
Please upload bright photos of your bare brows in various angles below. Up to 5 photos.
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Special requests, concerns or remarks for technician:
Please upload a valid photo ID to match your DOB and full name. Note: this photo uploaded is used for verification purposes only. You are more than welcome to block out DL #.
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Should be Empty: