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PERMANENT BROW CONSENT FORM
First Name
Last Name
Email
Street Address
Street address line 2
City
State
Zip Code
Phone Number
Select a date
Currently Pregnant
Yes
No
Currently Breastfeeding
Yes
No
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)
Yes
No
Had undergone Botox treatment
Yes
No
Has or any family history of Diabetes
Yes
No
Has Hepatitis A B C D
Yes
No
Had Forehead/Brow Lift
Yes
No
Had Facelift Surgery
Yes
No
History of Alcoholism
Yes
No
Has a Heart Condition
Yes
No
Had a Brow Lash Tinting
Yes
No
Has Autoimmune disorder
Yes
No
Has Oily Skin
Yes
No
Has, had, or any family history of having Cancer
Yes
No
Had undergone Chemotherapy/ Radiation
Yes
No
Taking or have taken acne treatments in the past 3 months
Yes
No
Had a Tan treatment
Yes
No
Difficulty numbing with dental work
Yes
No
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc
Yes
No
Allergic reaction to any medications
Yes
No
Allergies to metals, food, etc,
Yes
No
Any diseases other than listed here
Yes
No
Do you use facial care treatments?
Yes
No
Please list down any medications you are taking
Contact in case of emergency
First Name
Last Name
Email
Street Address
Street address line 2
City
State
Zip Code
Phone Number
Client/Parent/Guardian Signature
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I declare that the info I’ve provided is accurate & complete
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