Microblading Questionnaire
Name
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
Aspirin, Niacin, Vitamin E or Ibuprofen
*
Yes
No
Pregnant/Breastfeeding
*
Yes
No
Circulatory or Bleeding disorders
*
Yes
No
Serious diseases such as cancer, epilepsy, autoimmune disorders
*
Yes
No
On keloids or if you have tendency to keloid, birthmarks or moles.
*
Yes
No
Diabetic
*
Yes
No
Exposure To Strong Sunlight
*
Yes
No
Fruit or Milk Acid
*
Yes
No
Botox, Fillers, or Chemical peel
*
Yes
No
Any skin diseases symptoms or irritation on the area?
*
Yes
No
Currently on Accutane or other strong retinoid
*
Yes
No
Waxing
*
Yes
No
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