Medical History Form
Pre-qualification
Todays Date
MM/DD/YEAR
Name
First Name
Last Name
DOB
*
MM/DD/YEAR
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you had previous worked done on your eyebrows?
*
Yes
No
If ‘yes’ please fill in what service and how long ago.
Do you presently have or previously had any of the following:
*
Botox in the past 3 month
Diabetes
HIV
Currently are or have been on antibiotics in the past 2 weeks
Blepharoplasty (Eyelid surgery)
Hepatitis (A,B,C,D)
Brow lift
Easy bleeding
Face lift
Alcoholism
Eye surgery/ injury/ Corneal abrasion
Abnormal Heart Condition
Wear Contact Lenses
Chemical Peel (last treatment________) Pregnant currently
Breastfeeding
Brow or Lash tinting
Oily Skin
Accutane or acne treatment in the past year Keloid
Vegan
Cancer
Waxing in the past 2 weeks
Tan by booth or sun in the past 2 weeks
Difficulty numbing with dental work
Taking blood thinners: Aspirin, Ibuprofen ect.
Allergic reaction to any medications such as Lidocaine
Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?
Allergic to metals, foods ect
Any diseases or disorders
None of the above
Desire appointment date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Notes
Signature
*
I agree that all the above information is true and accurate to the best of my knowledge
Submit
Should be Empty: