Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have any scars in or around the brow area? *

Yes

No

Are you prone to Keloid scarring? *

Yes

No

Have you had a forehead lift? *

Yes

No

Have you had botox?

Yes

No

Do you use a retin-a/retinol? *

Yes

No

Do you have alopecia or trichotillomania (compulsive pulling of body hair)? *

Yes

No

Do you have eczema or dermatitis in or around the brow area? *

Yes

No

Do you have large pores? *

Yes

No

Do you have moles/raised areas in or around the brow area? *

Yes

No

Do you have or had a piercing in the brow area? *

Yes

No

Have you ever had a hair transplant for your eyebrows? *

Yes

No

Are you pregnant or nursing? *

Yes

No

Do you tan/use a tanning bed? *

Yes

No

Do you excercise frequently? *

Yes

No

Do you swim regularly? *

Yes

No

Do you have a Autoimmune disorder? *

Yes

No

Have you had cancer? *

Yes

No

Do you have allergies? *

Yes

No

Do you have any vacations planned within the next couple of months? *

Yes

No

Have you been previously microbladed?

Yes

No