Eyebrow Microblade Client Intake Form
For consultation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which service do you require
*
Full Tattoo Removal
Partial Removal
Microblade Eyebrow Ink Removal
MED.SPA
Health History
*
Do you have any allergies , especially to skincare products, medication or pigments ?
Yes
No
If Yes please list
Health History Other
Are you currently taking any medication ?
*
Yes
No
If yes please list
Current Medication
Do you have any of the following medical conditions
*
Diabetes
Blood Clotting Disorders
Skin conditions ( eczema, psoriasis etc )
Autoimmune Disorder
Pregnancy or Breastfeeding
Heart Condition
Cancer ( current or history )
Any Other Chronic Conditions ( please specify )
No
Other Chronic Conditions
Have You Had Any Previous Laser Treatments Or Skin Treatments
*
Yes
No
If Yes , please provide details
Previous Laser Treatments
Are you currently under the care of a dermatologist or physician for any skin related issues
*
Yes
No
If Yes , please provide details
Details
Eyebrow Microblade Tattoo History
*
Less than 6 months
6 months to 1 year
1-2 years
2 + years
What was the reason for having the microblading done
*
Aesthetic Enhancement
Correcting Uneven Brows
Filling In Space areas
Other ( Please Specify )
Reason for microblading
What is the reason you want the microblading removed
*
Poor Results
Over-arched Uneven Shape
Fading Unsatisfactory Color
Allegic Reaction
Change In Personal Style
Other ( please specify )
Other reason for removal
Doe you have any previous tattoos or ink in the area being treated
*
Yes
No
If Yes , please describe
Describe
Skin & Sensitivity . What is your skin type
*
Vary Fair
Fair
Medium
Olive
Dark
Have you had any adverse reaction to eyebrow microblading or other tattoo procedures
*
Yes
No
If yes please describe
Describe
Do you have any of the following skin reactions ( Please check all that apply )
*
Scarring
Hyperpigmentation ( dark spots )
Hyperpigmentation ( Light spots )
Excessive redness or irritation
Keloid scarring ( overgrowth of scar tissue )
Do you tan easily or use tanning products ( self-tanners, tanning beds
*
Yes
No
Have you recently been exposed to the sun or used a tanning bed
*
Yes
No
If yes, when was the last exposure
Last exposure
Laser Eyebrow Microblading Removal Information
*
Do you understand that laser ink removal may require multiple sessions for full removal and that the results may vary based on individual factors
Yes
No
Do you understand that there is a possibility of some temporary side effects such as redness, swelling, or scabbing after the procedure
*
Yes
No
Do you have any questions or concerns about the laser eyebrow microblading removal process
Consent & Acknowledgement
*
I hereby consent to the use of laser eyebrow microblading removal treatment as discussed with kplasertattoo. I understand that there are risks involved, including but not limited to scarring, changes in skin pigmentation, and discomfort during the procedure.I confirm that all the information provided in this form is accurate and complete to the best of my knowledge.,
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Practitioner Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
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