Brow Services Consultation and Consent Form

MEDICAL HISTORY QUESTIONNAIRE

Please answer the questions appropriately. This questionnaire will guide us for your upcoming treatments or services.

First Name *

Last Name *

Email *

Phone *

Date of birth *

Please tick the box if you are currently undergoing any of these medications. *

Acne Medication

Radiation or Chemotherapy

Please answer appropriately through ticking the box. *

I do not have any problems with healing.

I have not had any surgeries in the last year.

I have not had botox in the last two weeks.

I have not had any injectibles, glycolic peels or laser treatments in the last 6 months.

I have not had any skin treatments in the last two weeks

I have not been on Accutane, Retin A, Renova or Steroid Medication in the last 3 months.

I am not allergic to latex.

I am not pregnant and not breastfeeding.