Microblading Questionnaire

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
Should be Empty:

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