Consultation Form Release Form

Let us do this part
Today's Date:
Fri Nov 15 2019 05:49
Please read & answer
Do you have previous eyebrow/eyeliner tattooing?*
If yes, when?

Skin Type?*
Normal Dry Oily Combination

Are you pregnant or breastfeeding?*

History of Keloids or Hypertrophic scarring?*
If yes, explain:

Any known allergies to Lidocaine, Benzocaine, or Tetracaine?*

Botox, chemical peels, or any other treatments to eyebrow/face area in the last 3 months?*
If yes, explain:

Do you have any viral infections or diseases?*
It's okay if you do, your privacy is key.
Are you a diabetic? (Doctors written clearance required at time of appointment)*
(Doctors written clearance required at time of appointment)
Skin irritations or Psoriasis near the treated area?*
(rashes, sunburn, acne, etc.)
Are you currently or have you undergone chemotherapy?*

History of Epilepsy?*

Accutane in the past year?*

Do you have a pacemaker or major heart problems?*

Are you currently taking any medications?*
If yes, list ALL:

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Personal Info
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Date of birth:*
You must be 18 or older to have this procedure done.
Phone #:*

Photo ID(s)*
Please take a picture of your government issued photo ID