APPOINTMENT REQUEST FORM

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

4

Select any/all current conditions that apply:* This field is required.

Pregnant/Breastfeeding

Undergoing cancer treatment (Chemotherapy or Radiation treatment within last 12 months)

Under the age of 18

Have HIV, Hepatitis or any other infectious/viral diseases

Currently using or have been on Accutane within the last 12 months

Have trouble healing / are prone to develop infections easily

Routinely taking blood thinning medications

Epilepsy

NONE OF THE ABOVE

5

Which Service are you interested in?* This field is required.

6

Do you have existing Cosmetic Tattoo/Microblading on your eyebrows?* This field is required.

YESNO

7

If you have existing Cosmetic Tattoo/Microblading: Upload well-lit, clear images of your current eyebrows. One of your right eyebrow, one of your left eyebrow, and one face-on, selfie-style.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

8

Please upload any inspiration photos you have for your eyebrows.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

9

Would you prefer a morning or afternoon appointment?* This field is required.Appointment duration is approximately three hours

10

Which days of the week are you available? * This field is required.Appointment duration is approximately three hours

11

Have any questions? Please ask below