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Permanent Brows Consultation Form
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Email
*
Your email
Full Name
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Your answer
Address
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Mobile No.
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Your answer
Emergency Contact Name
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Your answer
Emergency Contact Number
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Your answer
Do you currently have or previously had any of the following:
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History of MRSA
Diabetes
Hepatitis (A, B, C, D)
Easy bleeding
Alcoholism
Abnormal Heart Condition
Pregnant now/ Breast feeding now
Autoimmune Disorder
Chemotherapy/ Radiation
Tumours/ Growths/ Cysts
Botox
Blepharoplasty (Eyelid surgery)
Forehead/Brow lift
Face lift
Eye surgery/ injury
Brow or Lash tinting
Oily Skin
Accutane or acne treatment
Tan by sunbed or sun
Chemical Peel in the last 3 months
Cancer
Required
Are you taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin? If yes, please leave details.
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Your answer
Are you allergic to anything?
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Your answer
Do you have any medical conditions or disorders not listed?
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Your answer
Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?
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Your answer
Please list medication or vitamins you’re presently taking
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Your answer
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