Brow PMU Consent and Health History

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Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Are you over the age of 18?*

YesNo
Check the conditions that apply to you:*

DiabetesCancerEpilepsyPregnant or BreastfeedingCardiac Valve DiseaseHistory of HSV1/HerpesHemophilia/Bleeding DisorderHIV/AIDSAllergy to LatexAllergy to Sulfa/AntibioticsImmunocompromisedAccutane in the past 12 monthsChemo/Radiation in the past 12 monthsLaser/Chemical Peel in the past 3 weeksFish Oil in the past 10 daysProne to infection (required antibiotics for dental work or surgeries)NONE APPLY
Please list all medications, prescriptions, or supplements taken in the past month:
Have you taken any antibiotics in the pat 30 days?*

YesNo
Have you had Botox or Filler in the past 3 weeks?*

YesNo
Have you had permanent makeup previously on your Brows or Lips?*

YesNo
Please list all allergies, medications, and medical conditions:
Date

MonthDayYear
Date
Enlightened Brows makes no attempt or claim to practice medicine. Some individuals will have complications related to permanent makeup application. The severity of these complications may vary.

Permanent Makeup is an artistic service. The look of the service and how the permenant makeup will heal varies from client to client. By signing below, you agree to understanding the risks related to having the service performed and consent to receiving the service.
Signature*

Clear
PRE/POST CARE REQUIREMENTS:

(PRE) The day of your appointment please avoid the following.
- Blood Thinners (advil, asprin etc.) Please do not stop taking doctor reccommended perscriptions without permission.
- Caffine (coffee, tea etc.)
- Alcohol
- Sun Tanning
- Exersice
- Intense Skin Care Products (exfoliation etc.)
(POST) For 7-10 days following your appointment, please plan on avoiding the following.
- Getting the serviced area wet (swimming etc.)
- Direct sun exposure (tanning etc.)
- Exercising/Sweating
- Makeup on the serviced area
- Skincare on or around the serviced area
I HAVE READ AND UNDERSTAND THE PRE/POST CARE REQUIREMENTS*

YESNO
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