Eyebrows Questionnaire
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First and Last Name *
Phone Number *
Email Address *
Why are you interested in having your brows done? *
Have you received any permanent makeup to your brows in the past? *
If yes to prior PMU on your brows, when was the last time they've been touched? An approximation is okay.
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Do you have Botox? *
If yes, when was the last time you received it (an approximate date is okay)?
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DD
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YYYY
Do you have any thyroid conditions? *
Do you have Trichotillomania? *
Are you currently on medication for high blood pressure? *
Are you currently on blood thinning medication? *
List of all current medications you are taking: If none, please put "N/A" below *
Are you currently pregnant or breastfeeding? *
When were you looking to have this procedure done? *
Do you have any upcoming trips? *
If yes, what is the date of your trip?
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DD
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If maybe, when approximately do you think you'll be going?
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YYYY
Will you be in sun and/or water on your trip? *
How did you hear about me? Who referred you? *
Preferred method of communication: *
Do you have any questions? Please list them below.
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