Consultation Form

Consultation Form
Please answer all the questions below so I can determine if the treatment is suitable for you you. Once submitted I will review and will be in touch within 24hrs.

If any medical or skin conditions aren't declared in the form below, you will not be eligible for a deposit refund if I determine at the appointment that you're not suitable for the treatment, so please take a good look at the skin under your eyebrow hair. If the skin is red or dry or has small red or white bumps or visible blood vessels then please indicate that in the form below. It's very important as you may not be suitable for the treatment!
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Age
What are your goals and expectations of the treatment? *
Have you previously had Microblading or eyebrow tattoo? *

Yes No
Please specify where and when?
What skin type do you have? *

Oily Dry Normal Sensitive Sun Damaged Bleeds easily
Do you have any of the following skin conditions on your face, specifically on the brow area. Please take a good look at the skin under your eyebrow hair before answering this question.

Eczema (red itchy skin), Rosacea (red skin/visible blood vessels), Psoriasis (small rough to the touch red bumps in places where the hairs come out of the skin), Acne (whiteheads/blackheads or pimples), Dermatitis (itchy dry skin or a rash)
Do you routinely use Retin-A, Glycolic or other exfoliating products?

Yes No
Do you tend to develop keloid or hypertrophy scars?

Yes No
Do you smoke? *

Yes No
Have you ever used or currently using medication or cream to treat Acne? *

Yes No
Do any of the following apply to you? *

Scarring (over brow area) Melanoma /Moles (over brow area) Currently pregnant Current breast feeding Botox injections Collagen Injections Heart Disease Diabetes Hepatitis c HIV Healing problems Haemophilia (Bleed severely) Clotting Disorders High blood pressure Low blood pressure Hypertension (abnormally high blood pressure) Epilepsy Cancer (radiation/chemotherapy) Anti – inflammatory medication Anti-coagulants medicine (Blood thinning, warfarin, aspirin etc) NONE
If you ticked any of the above, please specify
Are you currently being treated for a condition not listed? *

Yes No
Please specify
Are you currently taking medication? *

Yes No
If yes please specify
Do you have any allergies to metals or cosmetics or hair dye?

Yes No
I confirm that all the information provided above is accurate to the best of my knowledge.
Signed

Clear
Date

Month Day Year
Date
How did you hear about us *
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