Powder Brows Intake Form

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Name(Required)
Address(Required)
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Emergency Contact(Required)
Do you have any known allergic reactions or sensitivities to any topical or local anesthetics?(Required)
Are you allergic to lidocaine or any other numbing agents?(Required)
Do you have any allergies (i.e. Polysporin, Bacitracin, Neosporin, Latex, etc.)?(Required)
Are you currently pregnant or breast-feeding?(Required)
Do you bruise easily?(Required)
Does your skin swell easily?(Required)
Do you have any heart conditions or high blood pressure?(Required)
Do you have or do you think it is possible that you have any blood borne communicable disease such as HIV or Hepatitis?(Required)
Do you have any serious medical conditions?(Required)
Do you have diabetes, currently on any form of immunosuppressant therapy or any condition that may delay healing?(Required)
Do you suffer from any form of hyperpigmentation (dark spots)?(Required)
Do you have any known personal history or family history of Methemoglobinemia (blood disorder)?(Required)
Have you ever had a Herpes Simplex Type 1 infection?(Required)
Do you use Retin A or Glycolic Acid products?(Required)
Are you prone to keloid scarring or any other form of excessive scarring condition?(Required)
Do you have a bleeding disorder or take blood thinners?(Required)
Are you allergic or sensitive to any metals?(Required)
Have you had any form of cosmetic or surgical procedure (botox, injections, laser therapies, facelifts, etc.), Radiotherapy or Chemotherapy at any time within the last 6 months?(Required)
Do you have any chronic or acute eye disease?(Required)
Photo Release: Permission is granted to take before and after photos of my brows / face which may be used for marketing purposes on a website, salon or class.(Required)
Signature (your name submitted below will be considered your electronic signature.)(Required)
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