Health declaration

Please fill out the following form.

First name

Last name

Email

Phone

Date of birth

Month

Day

Year

What service are you receiving?

Have you had previous permanent makeup in this area? If yes, please explain

Are you currently taking blood thinners?

Yes

No

Do you have diabetes?

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Do you have a history of keloids or hypertrophic scarring?

Yes

No

Do you have any allergies (especially to pigments, lidocaine, latex)?

Yes

No

Are you currently using Accutane or have used it in the past 12 months?

Yes

No

Have you had Botox or fillers in the treatment area within the last 3 weeks?

Yes

No

Do you have any skin conditions in the treatment area (eczema, psoriasis, etc.)?

Yes

No

Have you used any retinoid products in that last 3 weeks?

Yes

No

If you answered yes to any of the questions above, please supply additional information.

I declare that the info I’ve provided is accurate and complete.