Microblading Client Information Form
Today's Date
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Month
-
Day
Year
Date
Name
First Name
Last Name
Your Date of Birth
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Month
-
Day
Year
Date
Phone Number
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Area Code
Phone Number
Email
example@example.com
List any and all allergies
List any prescribed medications you are currently taking:
Have you ever had your eyebrows tattooed or microbladed?
Yes
No
If yes, when did you have them done?
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Month
-
Day
Year
Date
If yes, how was your healing?
Do you have any scars, including Keliod scarring, in or around the brow area?
Do you have a forehead lift?
Yes
No
If yes, when?
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Month
-
Day
Year
Date
Have you had Botox or Fillers anywhere from the eyes up?
Yes
No
If yes, when?
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Month
-
Day
Year
Date
If yes, exact location of the injections, for example in between brows, forehead, crows feet...etc
Do you have alopecia or trichotillomania (complusive pulling of hair)?
Yes
No
Alopecia
Trichotillomania
Do you have eczema or dermatitis in or around the brow area?
Yes
No
Do you have large pores?
Yes
No
How would you describe your skin type?
Oily
Dry
Normal
Combination
Sensitive
Do you have moles/raised areas in or around the brow area?
Yes
No
Do you have or have had a brow piercing?
Yes
No
Not anymore, no raised scar
Not anymore, with scarring
Have you had an eyebrow hair transplant?
Yes
No
Do you tan in a tanning bed?
Yes
No
Do you exercise?
Moderately
Not really
3-4 times a week
As much as you can
Have you had Chemo or Radiation in the last 6 months?
Chemo
Radiation
No
Medical History
Have you ever had MRSA?
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
Do you have diabetes?
Yes
No
If yes, explain:
Do you have Hepatitis A, B, C, D, E
A
B
C
D
E
No
Have you had any facial surgeries? If yes, list all surgeries below with dates.
Any history of alcoholism?
Yes
No
Do you have an abnormal heart condition? If yes, explain:
Are you currently pregnant or breastfeeding?
No
Pregnant
Breastfeeding
Do you have an auto immune disease? If yes, explain:
Have you ever been diagnosed with cancer? If yes, explain and are you in remission?
If yes, when?
-
Month
-
Day
Year
Date
Do you have tumors, growths, or cysts within the face?
Yes
No
If yes, explain:
Are you currently taking any blood thinners?
No
Aspirin
Ibuprofen
Alcohol Daily
Coumadin
Fish Oil
Xarelto
Eliquis
Heparin
No
Are you currently taking Accutane?
Yes
No
Have you had a chemical peel within the past 30 days?
Yes
No
Does your skincare routine consist of anything with Retin-A, Retinols, or any other exfoliating acids or buffing agents? Please list all, plus what brand:
Are you currently under the care of an esthetician, plastic surgeon, dermatologist, or any general spa where you receive facial treatments? If yes, please list which one:
Submit
Should be Empty: