Medical history and client information
If you are human, leave this field blank.
Name
DOB
Address
Contact Number
Procedure Desired
T/L
B/L
E/B
L/L
F/L
M/B
Select Desired Procedures
Allergies
List any allergic reaction to drugs, make-up, skin or food and describe.
Eyes / Eyebrows
Contact lenses
Dry eyes
Eye makeup sensitivity
Blurred vision
Glaucoma
Thyroid abnormalities
Alopecia (total)
Alopecia (local)
Other hair loss
Pull out lashes/brows compulsively
Cataracts
Eye surgery
Corneal abrasions
Blepharoplasty (eye lift)
Use of eye drops or meds
Brow tinting
Select options that describe your current conditions
Last date of Brow Tinting:
Lips
Cold sores (prescription of antiviral required)
Collagen injections
Fat transfer (botox)
Injections
Select options that describe your current conditions
Collagen injections & Injections:
Skin: Other Tattoos?
Use of sunbed / suntan outdoors
Currently using Retin A
Currently using glycolic, bha, aha products
Have you ever had a chemical peel
Any keloids or hypertrophic scars
Bruise/bleed easily / healing problems
Other dermatological disorders
General Medical
High blood pressure
Diabetes
Prolonged bleeding
Blood clotting disorders
Heart problems
Heart palpitations
Blood thinners (aspirin,alcohol)
Fainting/dizziness
Pregnant/nursing
Accutane/cortisone last 6 months
Seizures
Autoimmune disorders
HIV/Aids
Chemotherapy/radiation
Cancer/tumors/growths/cysts
Smoke
Hepatitis
List any surgeries:
Any planned surgery
List any medication
Under physicians care
Yes
No
I have produced a written consent from my Physician to allow for procedure
Yes
No
Physician’s Name
Physician’s Number
I CONFIRM THAT THE INFORMATION GIVEN IS CORRECT_SIGNATURE
Date
Submit