Name *
Name
Phone *
Phone
Are you 18 or older? *
Are you currently pregnant or nursing? *
Are you allergic/sensitive to Licodaine? *
Are you allergic/sensitive to latex? *
Are you allergic to any metals? *
Do you have history of keloids? Hyperpigmentation? Hypopigmentation? *
Do you have any scarring or skin conditions on or around the brow? *
Have you had any permanent eyebrow work done before? *
Have you had botox in the last 2 weeks? *
Have you had any chemical peels/waxing in the last 4 weeks? *
Have you ever used/are currently using Accutane (Acne Medication?) *
Are you currently taking any antibiotics? *
Are you currently taking blood thinning medication? (ex: Aspirin) *
Do you take prescription drugs? *
Do you have any drug allergies? *
Are you diabetic? *
If yes, medical clearance is required.
Do you have uncontrolled high blood pressure? *
Do you have blood borne illness? (HBV, HCV, HIV, etc?) *
If yes, medical clearance is required.
Do you have history of cold sores/HSV-1/HSV-2? *
Do you have any skin disorders such as Shingles, Rosacea, Eczema, and Psoriasis and are they active? *
Is there any reason you would need to consult your doctor for medical clearance before receiving a tattoo? *
Reasons to contact your doctor before receiving Microblading, Permanent Make Up, or any Tattoo: Are you on: - Blood thinners such as Coumadin, etc. - Steroids such as Prednisone - Currently on or scheduled for Chemotherapy? - Recently had or scheduled for surgery? - Do you have a heart valve replacement, stents, mitral valve prolapse, rheumatic fever or any heart condition?