Consultation Form
This form serves several important functions, ensuring both the safety of the client and the success of the treatment.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
*
First Name
Last Name
Emergency Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please attache a photo of your full face and brows without makeup, unfiltered, facing front and in natural lighting
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Medical History
Please answer the following questions honestly. All information is confidential.To assess the client’s health status and determine if any conditions or medications may affect the procedure, healing, or outcome. Go to our website at www.inkedbrowsintl.com to see the list of contradictions
Check the CONDITION/S that apply to you:
*
Cancer
Diabetes
Epilepsy
Pregnant
Breast feeding
History of HSV1/Cold sore
Hemophilia/Bleeding Disorders
Cardiac Valve Disease
HIV/AIDS
Allergy to Sulfa/Antibiotics
Allergy to Latex
Allergy to Anesthetic/Numbing agents
Immunocompromised
Accutane/Isotretinoin in the past 12 months
Chemo/Radiation in the past 12 months
Laser or Chemical peel in the last three weeks
Prone to infection/ Require antibiotics for dental works
NONE APPLY
Back
Next
Do you have ALLERGIES?
*
YES
NO
If you answered YES, please specify:
Back
Next
Are you currently taking any MEDICATION?
*
YES
NO
If you answered YES, please specify:
Back
Next
Do you have a history of COLD SORES/ HERPES SIMPLEX?
*
YES
NO
Back
Next
Do you have any SKIN CONDITIONS? (e.g., eczema, psoriasis, acne) near the area treated
*
YES
NO
If you answered YES, please specify:
Back
Next
Do you have any MEDICAL CONDITIONS or CHRONIC ILLNESSES? (diabetes, autoimmune diseases, heart conditions & etc)
*
YES
NO
If you answered YES, please specify:
Back
Next
Have you taken any ANTIBIOTICS within 20 days of your scheduled appointment?
*
YES
NO
Back
Next
Do you have any BOTOX injections within 10 days of your scheduled appointment?
*
YES
NO
Back
Next
Do you have any history of KELOID SCARRING?
*
YES
NO
Back
Next
Do you have any history of poor wound healing or sensitivity to cosmetic procedures?
*
YES
NO
Back
Next
Have you had any PERMANENT MAKEUP or COSMETIC TATTOO before?
*
YES
NO
If you answered YES, please specify:
Back
Next
Have you had any reactions to cosmetic products or procedures in the past?
*
YES
NO
If you answered YES, please specify:
Back
Next
Procedure Information
Back
Next
Which procedure are you interested in?
*
Nano Brows
Nano Fusion
Powder Brows
Eyebrow Correction
Touch up (from a different artist)
Back
Next
What is your main goal or desired outcome from this procedure?
Back
Next
Do you have any specific concerns about the procedure or healing process?
*
YES
NO
If you answered YES, please specify:
Back
Next
Do you agree with our Terms of service and Privacy Policy written on our website?
*
YES
NO
Back
Next
What is the best way to get in contact with you?
*
EMAIL
TEXT
Back
Next
Best DATE/TIME for your appointment
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Back
Next
Upon reviewing your consultation form, we will contact you via EMAIL AND/OR TEXT MESSAGES to discuss the most suitable service for your skin type and address any additional questions you may have.
A Consent and Acknowledgment Letter will be sent to your email upon booking. Please review the document thoroughly and provide your signature to confirm your understanding and agreement.
Submit
Should be Empty: