Name
*
First Name
Last Name
DOB
*
DATE OF BIRTH
MM
DD
YYYY
Phone
(###)
###
####
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
social media consent
*
Do you consent to pictures and forms being used for case studies and shared on social media and my website. Please let me know if you'd like your pupils blurred out.
dr name
*
First Name
Last Name
gp phone number
(###)
###
####
dr Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have history of allergies/anaphylaxis?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Are you receiving any medical treatments?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Have you taken Accutane (Roaccutane) within the past 6 months?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Are you taking any hormone medication or contraception?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Do you have any cutaneous (skin) infections or inflammatory problems?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Are you currently taking any steroids, aspirin or anticoagulant?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Do you have any medical conditions?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Are you taking any topical medication?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Do you have any allergies?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Have you had any aesthetic treatments such as Skin Peels, microdermabrasion or Laser treatments?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Have you had Botox or Fillers? If so where on the face?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Have you been sunbathing or been on a sunbed in the last week? If so, did you burn?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Have you had Chemotherapy or Radiotherapy treatment?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Do you take any blood thinning or blood clotting agents?
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Is there any other medical condition that is not listed that we need to be aware of? Including HIV Hep B.
*
Y/N
YES
NO
IF YES, PLEASE SPECIFY
Consent
*
Thank you for taking the time to complete this form.
Upon review, I will get back to you with a confirmation to book an appointment.
You’re one step closer to your brow journey!
