Intake & Medical History Form

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Text: 512-548-2256 Call: 512-839-7098

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Designer Brows

INTAKE FORM

Please answer this form as accurately as possible. Your information will never be shared. These questions are just to be sure that any procedure offered here at Designer Brows is safe for you.

First Name

Email Address

Today's Date

Last Name

Date of Birth

Select Procedure

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Front of State Issued ID

Upload a copy of your State Issued Photo ID (Front Side)

Back of State Issued ID

Upload a copy of your State Issued Photo ID (Back Side)

Choose ALL that apply:

I am currently taking blood thinners

I am pregnant or breastfeeding

Rosacea

Seizures / Epilepsy

Pacemaker/defibrillator

I Use of topical accutane or Retin-A

Cold Sores

Recent dermal injections/filler (within 2 weeks)

Bruise Easily

Psoriasis

Lupus

Fibromyalgia

I have skin diseases such as psoriasis or eczema

I have taken pain medication within the past week

I have had a Chemical Peel within the past 4 weeks

I have had any type of laser procedure in the past 2 months

I have had a brow lift within the past 2 months

I have had facial cosmetic surgery within the past 6 months

I have issues with wounds healing

I have previous permanent makeup or tattoos on my face

I need a color correction

I need removal

I have an allergy to latex

I have allergic reactions to numbing creams or gels

I have issues numbing with dental work

I have a hormone imbalance

I am on Hormone therapy

I am going through menopause

I sweat often

I have Diabetes

I have a history of MRSA or Staph Infections

I have Hepatitis A B C or D

I bleed easily

I have had a facelift

I drink alcohol more than 3 times a week

I smoke Tabaco

I have an abnormal heart condition

I have an Autoimmune Disorder

I have Oily Skin

I have Dry Skin

I have had or do have cancer

I have had Accutane or acne treatments

I am undergoing Chemotherapy or Radiation

I have tanned by sun or booth within the past 30 days

I tan often (More than once a week)

I use lash or brow growth serum

I have Tumors

Growths or Cysts

I have allergic reactions to medications

I have a mental disorder

I suffer from depressionI have anxiety attacks

I am not happy with my overall appearance

I am on birth control

I have HIV / AIDS

High/low blood pressure

Keloid Scarring

None of the above

I understand that my personal or medical information will never be shared. This information is to ensure that this procedure is safe for me and my artist.

By selecting this box, I certify that I have answered all health questions honestly.

Micropigmentation is the process of implanting micro pockets of pigment into the epidermis and upper dermal layer of the skin. This is a form of tattooing used for permanent cosmetics. I voluntarily request my intradermal technician to perform the following procedures:

I Understand that there may be known and unknown risks and hazards related to the performance of the planned procedure and I understand that no warranty or guarantees have been made as to the results.

I Understand that photographs of the work performed to be taken both before and after treatment, and that said photographs may be used for purposes of advertising and/or training purposes. I may request full face photos to be approved before posting.