Medical Assessment Form
For Eyelash and Eyebrow Treatment
Full Name
*
First Name
Last Name
Date of birth
*
What is your gender?
Please Select
Male
Female
N/A
Mobile Number
*
Format: 07000 000000.
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Email Address
*
example@example.com
Are you pregnant ?
*
Yes
No
What are you hoping to treat ?
*
Eyelash growth
Eyebrow growth
Both
Click the condition that applies to your eyebrows/lashes
Both sides involved
Partial loss
Only one side involved
Only thinning (reduced density)
Total loss
Do you wear contact lens ?
*
Yes
No
Upload image of eyebrow/eyelashes
(optional)
Image
Upload Image
Drag and drop files here
Choose a file
JPG, PNG, GIF, max 10MB
Cancel
of
Click all current & past medical conditions
*
Chest pain
Respiratory
Thyroid disorder
Cardiovascular
Hematological
Hair loss
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Skin
Eye disorder
None
Click all eye conditions that you have
Conjunctivitis
Uveitis
Glaucoma
Eye infection
Dry eye syndrome
Other
None
If other, please list
Are you currently taking any medication?
Yes
No
Please list them.
Have you had eye surgery?
Yes
No
Provide details
Do you have any allergies?
Yes
No
Not Sure
Are you sensitive to face/eye cosmetics??
Please Select
Yes
No
List and describe sensitivity
Information Acknowledgement
I understand that this is an off-label treatment and requires assessment and consent to my information used to review and for treatment to be prescribed. I understand that results may vary and can take 6-12 weeks. I will read the information provided and aware that some of the side effects may include irritation, sensitivity, eyelid margin darkening and iris pigment changes
Submit
Should be Empty: