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NAME
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First
Last
EMAIL
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Email
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PHONE
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DATE OF BIRTH
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Have you had Cosmetic Tattooing on your eyebrows before?
*
Yes
No
What is your skin type?
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Normal
Dry
Oily
Combination
Are you able to use topical anesthetics? (lignocaine, tetracaine, prilocaine, epinephrine)
*
Yes
No
If your answer to any of the below are YES, please tick the check box next to the statement
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Are you pregnant?
Are you breast feeding?
Do you have diabetes?
Do you have hepatitis?
Do you have allergies?
Do you have glaucoma?
Are you allergic to latex?
Do you suffer from asthma?
Do you have a blood disorder?
Do you have heart conditions?
Do you have recent scar tissue?
Are you iron deficient or anemic?
Do you have auto immune disease?
Do you suffer from keloid scarring?
Do you have problems with healing?
Do you suffer from high or low blood pressure?
Do you suffer from mild eczema or psoriasis?
Are you currently taking acne medication?
Are you currently using retin-a or alpha hydroxy skin products?
Do you suffer from reactions to vasline or petroleum base?
Are you currently undergoing chemotherapy or radiation?
I have none of the above
Please list all health concerns and medications you are taking:
Comments, questions?
I have read and understood all the information listed above and answered each question truthfully
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YES
Please attach clear images of your eyebrows for assesment (clear lighting, no filters & no makeup)
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