New Client Online Consult
Rad Brows and More
Full Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Rad Brows and More?
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Please mark all of the following that apply to you!
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I am allergic/sensitive to Lidocaine
I am allergic/sensitive to latex
I have been pregnant in the last 12 months
I am currently pregnant
I am currently breastfeeding
I have a hormone condition that is not well managed and/or under control
I have a thyroid condition that is not well managed and/or under control
I frequent tanning beds
I use exfoliating facial products daily
I wear contact lenses
I am prone to cold sores/Herpes/fever blisters
I am taking prescription blood thinning medications
I have a blood borne illness
I have had previous permanent makeup done (IF YES, USE “OTHER” SECTION TO TALK ABOUT WHICH PROCEDURE YOU GOT DONE, HOW LONG AGO, HOW MUCH COLOR REMAINS)
I have diabetes that is not well managed/under control
I am currently using eyelash growth serums or have used them in the last 6 months
I have been on Accutane in the last 12 months
I have had shingles on my face
None apply to me
Other
If “other” was marked, please explain further
I am interested in
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Brows
Lips
Brows and Lips
Brow Correction
Lip Correction
Other
Please indicate ALL medications, vitamins, and supplements that you're currently taking. Certain medications can affect healing/the procedure. Please include prescriptions and/or over the counter medications.
*
Please use this box to let us know if anything mentioned above needs an explanation
If I checked “yes” that I am prone to Herpes/cold sores/fever blisters, I am required to consult with my physician about anti-viral options BEFORE scheduling a LIP PROCEDURE. I understand that it is my responsibility and that I may be asked to show proof of approval/prescription prior to beginning the procedure. An outbreak during healing can disrupt the final result of my procedure and this will not be the fault of the technician
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Yes
No
Not applicable
Appointment date *only if accidentally scheduled before filling out this form*
Please attach a BRIGHT, CLEAR, MAKEUP-FREE photo of your beautiful face! It is best to have someone take a photo for you. Please do not send blurry or low quality photos
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Signature
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I have answered all questions honestly and to the fullest extent of my knowledge. I understand that by not being honest with my medical history and background, it could negatively affect my procedure’s outcome. Rad Brows and More reserves the right to refuse any service, at any time.
Date Signed
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Month
-
Day
Year
Date
Once you have completed this form, please submit down below. Your information will go directly to Rad Brows and More. You may proceed to book online, no need to wait for a call first.
If needed, the technician will call you for additional information.
Submit
Submit
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