First Name *

Last Name *

Date of birth - You Must Be Over 18 For This Treatment *

Email *

Phone *

Are you currently taking any medications? *

Yes

Please List Any Medications Taking: *

Do you have any allergies? *

Yes

Please List Any Allergies

Are You on Roaccutane for acne or any other prescribed acne medication *

Yes

Do you have any open sores on the face or active skin conditions such as eczema? *

Yes

Have you recently been unwell? *

Yes

Please Provide Details Of Illness:

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

Have you had Microblading or other Permanent Makeup before? *

If Yes When did you last have Microblading / Permanent Makeup done?

Did you have any problems with healing afterwards? *

If Yes Please Provide Details:

Do you have any implants? *

Do you have any Botox or other injectables? *