Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
How did you hear about Hawaii Brow Studio?
*
1. Are you pregnant?
*
Yes
No
2. Have you had any alcohol in the last 24 hours?
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Yes
No
3. Have you had cold sores or fever blisters?
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Yes
No
4. Do you have any allergies to latex?
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Yes
No
5. Have you had a laser or chemical peel in the last 6 months
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Yes
No
6. Have you ever had any permanent makeup or tattoos applied?
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Yes
No
7. Do you bruise easily for no obvious reason
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Yes
No
8. Do you routinely use Retin-A, glycolic or other exfoliating products
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Yes
No
9. Do you wear contact lenses
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Yes
No
10. Are you allergic or sensitive to any metals for instance metals used for jewelries?
*
Yes
No
11. Do you have any problems healing?
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Yes
No
12. Is your skin oily?
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Yes
No
13. Do you use tobacco? If you use tobacco you may heal slower and this affects the timing on scheduling a touchup appointments, if applicable.
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Yes
No
14. Do you have any heart conditions?
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Yes
No
15. Are you diabetic? If so Type 1 or Type 2?
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Yes
No
16. Do you have any autoimmune disorders?
*
Yes
No
17. Are you sensitive or allergic to hand creams or body lotions?
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Yes
No
18. Do you have you lips injected with filler materials?
*
Yes
No
19. Do you menstruate? If yes: Next cycle date: ____________
*
Yes
No
If yes: List next cycle date
20. Do you hyper pigment? (Tendency to develop dark spots on the skin from wounds?
*
Yes
No
21. Do you tend to develop Keloid or hypertrophy scars
*
Yes
No
22. Do you scar easily from minor skin injuries?
*
Yes
No
23. Do you have seizure related conditions?
*
Yes
No
24. Do you have tendency to faint or become dizzy?
*
Yes
No
25. Do you bleed excessively from minor cuts?
*
Yes
No
26. Do you have prosthetic implants?
*
Yes
No
27. Do you consume aspirin daily
*
Yes
No
28. Are you under treatment for depression
*
Yes
No
29. Are you sensitive to petroleum based products?
*
Yes
No
30. Do you have botox injections?
*
Yes
No
31. Are you undergoing radiation or chemo-therapy treatment?
*
Yes
No
32. Are you now or have you ever been on acne treatment Acutane
*
Yes
No
33. Are you wearing a pacemaker?
*
Yes
No
34. Do you take prescription drugs?
*
Yes
No
35. Are you anemic?
*
Yes
No
36. Do you have a history of skin sensitivities?
*
Yes
No
37. Do you have any medical conditions that has resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedures?
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Yes
No
38. Do you have allergies to makeup?
*
Yes
No
39. Do you have dry eyes?
*
Yes
No
40. Do you intentionally tan in direct sun or tanning bed?
*
Yes
No
41. Do you have any history of Cancer?
*
Yes
No
42. Do you have history of stroke or heart attack?
*
Yes
No
43. To you knowledge are you allergic or resistant to over the counter level numbing products such as ELA-Max?
*
Yes
No
44. Do you hypo-pigment? (Lack of pigment on the skin
*
Yes
No
45. Are you allergic to hair dyes
*
Yes
No
46. Do you have glaucoma or any other eye disease?
*
Yes
No
47. Do you have high or low blood pressure?
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Yes
No
48. Do you have any type of Hepatitis?
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Yes
No
If you answered “yes” to any questions above, use the space below to provide explanation. Correlate your explanations to a specific question number. A “yes” answer does not indicate you are not an acceptable candidate for permanent cosmetics.
Signature
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