IMPORTANT NOTICE: Consultations are $25 and will go toward the procedure if we book. This holds your spot and is NON-REFUNDABLE in the event of a no-show, deciding not to book an appointment, OR if appointment is not cancelled/rescheduled within 48 hrs. If you have had previously tattooed eyebrows you must inform me prior to consultation as it is not always possible for me to tattoo over. Please review the information below before booking a consultation.
Name:____________________________
Address/City/State/Zip:____________
_________________________________
D.O.B.______________
Phone Number:____________________
Doctor’s Name:____________________
CHECK YES NO
In Menopause _____ _____
Pregnant _____ _____
Maybe Pregnant _____ _____
Nursing _____ _____
Cold Sores/Herpes _____ _____
Contact Lenses _____ _____
Eczema/Dermatitis _____ _____
Latex Allergy _____ _____
Shingles _____ _____
Heart Condition _____ _____
Hemophilia _____ _____
Keloid Scars _____ _____
Pacemaker _____ _____
Bleeding Disorder _____ _____
Problems w/ healing_____ _____
Diabetes _____ _____
Anemia _____ _____
Cancer _____ _____
Chemotherapy _____ _____
Seizures _____ _____
Smoker _____ _____
Are you allergic to Lidocaine, Tetracaine, Benzocaine Novocain or Epinephrin?
Yes___No___
Have you taken Accutane in the past year?
Yes___ No___
Have you ever had permanent makeup
done in the past?
Yes___ No___
If so, when?_____________________
Pigments used? __________________
Are you currently taking any blood thinners such as Aspirin, Fish oil, etc?
Yes___ No___
Do you use Retin-A products?
Yes___ No___
Have you had Botox in the last 6 months?
Yes____ No____
Medication Allergies:
1________________________________
2________________________________
3________________________________
Food/Product Allergies:
1________________________________
2________________________________
3________________________________
Previous Surgeries:
1____________________Date________
2____________________Date________
3____________________Date________
Current Medications:
1________________________________
2________________________________
3________________________________
4________________________________
I Acknowledge that all of the above information contributed by me is true and accurate.
Print Name_______________________
Signature_________________________
Date__________________