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__________________