Brittany Allen
Behind the Chair Salon
Online Consult Form
After completing form I will contact you for scheduling or any follow up questions!
Full Name
*
First Name
Last Name
Email
example@example.com
Contact Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age:
*
Referred by?
*
Please mark all that apply :
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I am allergic/sensitive to Lidocaine
I am currently breastfeeding
I am allergic or sensitive to latex
I have a hormone condition that is not well managed and/or under control
I have been pregnant in the last 12 months
I have a thyroid condition that is not well managed and/or under control
I am currently pregnant
I frequent tanning beds
I use exfoliating facial products daily
I wear contact lenses
I am prone to cold sores/herpes/fever blisters
I have a blood borne illness
I have uncontrolled high blood pressure
I am taking prescription blood thinning medication
I have had previous permanent makeup (IF YES, PLEASE USE LOWER SECTION TO TELL US WHICH PROCEDURE, HOW LONG AGO, AND EXACTLY HOW MUCH COLOR REMAINS)
I have diabetes that is not well managed or under control
I have been on Accutane in the last 12 months
I am currently using eyelash enhancing serums, or I have in the last 6 months
I have had shingles on my face
None
Other
I am interested in:
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Eyeliner/lash enhancement
Brows
Other
Are you currently taking any medication?
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Yes
No
Please list them. Include all Vitamins, and supplements you regularly take. Certain medications can affect the healing and/or procedure itself. Please include all prescription and over the counter medications.
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Please use this comment box to tell us about any items listed above that may need a short explanation. If you marked that you have had your permanent makeup previously done, please let us know how long ago, which procedure, and how much color remains.
*
If I have checked "yes" that I am prone to Herpes/Cold Sores/, I am required to consult with my Physician about anti-viral options before scheduling a LIP procedure. I understand that it is my responsibility and that I may be asked to show Physician Approval and/or Prescription prior to beginning my procedure. An outbreak during healing can disrupt the final result of my procedure, and this will not be the fault of the technician.
*
Please Select
Yes
No
Not applicable
Please attach a BRIGHT, CLEAR, MAKEUP-FREE photo of your brows or eyeliner. It is typically best to have someone else take the photo for you. Please do not send blurry photos.
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