Brow consultation form
Laura Mercy Brows
All about you
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
How would you describe your skin on your forehead?
*
Dry
Oily
Normal
Mixed
Have acne
Sensitive
Pores
Aged skin
Hyperpigmentation
Please upload a photo of your brows (please use back camera)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What look are you desiring?
*
Natural Microblading
Microblading with shading
Combination brow
Unsure
Have you had semi permanent brows before?
*
Yes- still have pigment
Yes but its no longer there
Never
Back
Next
MEDICAL HISTORY
Please answer these to the best of your knowledge
Heart conditions?
*
Please Select
Currently
Previously
Never
Pacemaker etc
Skin conditions?
*
Please Select
Currently
Previously
Never
Eczema, impetigo, psoriasis or acne?
Do you suffer from keloids or Hypertrophic scars?
*
Please Select
Currently
Previously
Never
Communicable diseases?
*
Please Select
Currently
Previously
Never
Hepatitis, AIDS, HIV, MRSA etc
Blood thinning conditions?
*
Please Select
Currently
Previously
Never
Haemophilia, clotting etc
Blood thinning medication?
*
Please Select
Currently
Previously
Never
Diabetes?
*
Please Select
Type 1
Type 2
None
Epilepsy?
*
Please Select
Currently
Previously
Never
Seizures?
*
Please Select
Currently
Previously
Never
Allergies?
*
Please Select
Currently
Previously
Never
Food, plasters, micropore tape, metals or skin care products?
Pregnant or breastfeeding?
*
Please Select
Yes
No
Blood pressure?
*
Please Select
High
Low
Normal
Do you suffer from fainting?
*
Please Select
Yes
No
Previously
Do you suffer from hair loss or alopecia?
*
Please Select
Currently
Previously
Never
Autoimmune disease?
*
Please Select
Currently
Previously
Never
Please write below what you suffer from.
Cancer, Leukaemia, Lymphoma, Timeouts, Growths or cysts?
*
Please Select
Currently
Previously
Never
Please write below what you suffer from or have suffered from.
Radiotherapy or chemotherapy?
*
Please Select
Currently
Previously
Never
Please write below when these treatments took place.
Had any surgeries within the last 3 months or any pending?
*
Please Select
Yes
No
Please write below when these took place.
On any medication?
*
Please Select
Yes
No
Please write below what these are and a brief description of what for.
Please give any further details of any of those which you have answered yes to. You may be asked to seek GP authorisation before proceeding with your appointment.
*
Please tick if yes
Do you use sunbeds?
Skin products (retinol, glycolic acid or alpha hydroxyl)?
Do you bruise or scar easily?
Chemical peels?
Submit
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