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Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

ARE YOU CURRENTLY USING ANY MEDICATIONS?

YES

NO

ARE YOU PREGNANT OR BREASTFEEDING?

YES

NO

ARE YOU ALLERGIC TO TOPICAL ANAESTHETIC? (LIDOCAINE, TETRACAINE, EPINEPHRINE)

YES

NO

DO YOU HAVE ANY HEALTH CONCERNS?

YES

NO

HAVE YOU EVER HAD YOUR BROWS TATTOOED, MICROBLADED, ETC?

YES

NO

ARE YOU IRON DEFICIENT OR ANEMIC?

YES

NO

DO YOU SUFFER FROM KELOID SCARRING?

YES

NO

WHAT IS YOUR SKINTYPE?

DRY

NORMAL

COMBINATION

OILY