PMU Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Todays date

Date

4

Are you 18+ years of age?* This field is required.

Yes

No

5

Are you currently breastfeeding or pregnant?* This field is required.

Yes

No

6

Are you diabetic?* This field is required.

Yes

No

7

Do you have keloids, psoriasis, or eczema on the brows or brow area?* This field is required.

Yes

No

8

Have you had Botox in the treatment area in the last 1-3 months?* This field is required.

Yes

No

9

Are you undergoing chemotherapy?* This field is required.

Yes

No

10

Do you have any blood disorders?* This field is required.

Yes

No

11

Do you have cancer?* This field is required.

Yes

No

12

Note: If you answered 'yes' to any of the medical questions, you are required to provide a letter of approval from your Primary Care Physician stating that you are allowed to undergo the Ombrè Brows PMU procedure.

13

Do you have virgin brows (no other tattoo/PMU work has been dont to the brows)?* This field is required.

Yes

No

14

Email* This field is required.

example@example.com

15

Please upload a picture of your photo ID* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

16

Please upload a front facing photo of your face without makeup or filters (look straight forward at the camera).* This field is required.Photo

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.* This field is required.