Eyebrow Microblading & SPMUDisclaimer & Consent Form. Name * First Name Last Name DOB * MM DD YYYY Phone (###) ### #### Email * Emergency Contact * Please list your emergency contact & phone number Are your brows currently tinted? * Yes No Have you had Botox in the past two weeks? * Yes No Are you currently pregnant/breastfeeding? * Yes No Do you presently have, or a have a history of easy bleeding? * Yes No Have you had MRSA in the past 2 weeks? * Yes No Do you presently have, or a have a history of diabetes? * Yes No Do you presently have, or a have a history of Hepatitis A, B, C, D * Yes No Have you had a forehead or brow lift? * Yes No Have you had a facelift? * Yes No Do you presently have, or a have a history of with alcoholism? * Yes No Do you presently have, or a have a history of an abnormal heart condition? * Yes No Do you presently have, or a have a history of taking meds before dental work? * Yes No Have you had a chemical peel in the past two weeks? * Yes No Do you presently have, or a have a history of an autoimmune disorder? * Yes No Do you have oily skin? * Yes No Do you presently have, or a have a history of cancer * Yes No Do you presently have acne, or are on Accutane? * Yes No Are you presently going through radiation or chemotherapy? * Yes No Have you used a sunbed / been tanned by the sun in the last two weeks? * Yes No Do you presently have, or a have a history of Tumours, Growths, Cysts or Poor Scarring? * Yes No Do you have a history of difficulty numbing with dental work? * Yes No Are you or have you taken any blood thinners such as Aspirin, Clexane, Ibuprofen, Alcohol, Coumadin in the past 2 weeks? * Yes No Do you presently have, or a have a history of any allergies? * Yes No If 'yes' please list allergies below Any disorders that you know of that aren't listed I agree that all the information that is listed is true & accurate to the best of my knowledge * Yes No What services are you interested in? * Please select all that apply Microblading Microshading Blade & Shade Faux Freckles Today's Date * MM DD YYYY Thank you!