Brow Correction/Cover Up Evaluation Form

Brow Correction/Cover Up Evaluation Form

This form is to help determine if you are a good candiate for brow correction/ cover up.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MicrobladingPowder BrowBlade & ShadeOld School Brow TattooingNano Strokes
What year did you have this procedure?*
How many times have you had them done?*
What is the name of the business/ artist you went to?*
Did you have an issue with healing after your procedure?*
Please describe your brows. (What are you looking to change, what do you not like, etc). Be as specific as possible.*
Has any of the pigment turned red, pink, blue, purple, or green?*
Have you had any laser or saline removal sessions on your brows?*
If so, when and how many sessions were completed?
Please upload a clear selfie, makeup free, forward facing camera, in good lighting.*
Please upload a clear photo of both brows up close.*
Please upload a close up of your left brow.*
Please upload a close up of your right brow.*

Please check below if you have any of the following medical conditions.*

Rows	Yes	No	Explain
Cold Sores/Fever Blsiters
Heart Conditions (Pacemaker, Defibrillator)? Autoimmune Dissorder
Cancer
Bleeding Disorder
Hyperpigmentation
Keloid/Hypertrophic Scarring
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV Positive
Venereal Disease
Asthma
Thyroid Condition
Iron Deficiency Anemia
Radioation Therapy or Chemotherapy
Eye Disorder
Trichotillomania
Skin Disorders (Rosacea, Eczema, Psoriasis, Dermatitis)?
Hereps
Alopecia