SALINE REMOVAL CONSULTATION FORM

Name*

First NameLast Name
Email*
example@example.com
Birth Date*

MonthDayYear
Do you have any of the following medical or skin concerns - especially in the area of the tattoo - that I should be aware of? (Check all that apply)

AcneEczemaPsoriasisMoles/BirthmarksCancerChemotherapyPregnant/NursingOther
If other, please explain:
What technique was used? (Brow's only)*

MicrobladingOmbre Shading/Powder BrowsA combination of Microblading and shadingI'm not sure
How many times have your eyebrows been Microbladed/tattooed (including any touch ups)?*
When was the last time your eyebrows were microbladed/tattooed?*
Did Bethany do your previous Microblading/tattoo?*

YesNo
Have you tried other removal methods?*

YesNo
Please describe what makes you unhappy about your current brows/previous Microblading/Tattoo.*
What goals would you like to achieve for your brows/tattoo with this procedure? i.e Complete removal or lightening?*
Do you plan to have your eyebrows Microbladed/tattooed again in the future?*

YesNoUnsure
Please submit clear photos of your current brows below. (It it usually helpful to have someone else take the photos for you if possible. )*

Cancelof
Should be Empty: