Surveypoint

Q1

First Name

Full Name*

Q2

Last Name

Full Name*

Q3

Phone Number

Phone Number*

Q4

Email*

Q5

Date of Birth*

Q6

Concerns with your current brows:*

Q7

Current Medications and/or Herbal Supplements: *

Q8

Allergies to Medication or Food: *

Q9

Previous Surgeries or Cosmetic Procedures: *

Q10

Have you used or have you had any of the following:*

Botox in the last 4 weeks

Accutane

Laser Resurfacing

Sunburn on your face

Retin-A Burns

Liposuction on your face

Chemical Peel

Photo-Derm Skin Grafts

Intense Light Glycolic Acid

None of the above

Q11

If yes please provide date and on which area:

Q12

Do you have or had any of the following:*

Injectable fillers in the last 6 months - Brow Area

Currently Pregnant and/or breastfeeding

Menopause

Hormone Imbalance

Latex Allergy

Problems with Healing

High Blood Pressure

Bleeding Disorder

Dermatitis/Eczema

Cancer

Cold Sores/ Herpes

Diabetes

Heart Condition/Pacemaker

Hepatitis

HIV

Hemophilia

Keloid Scars

Allergy to Red Lake 5

Hyper Pigmentation

Any active infections

Smoker

None of the above

Q13

Are you currently under the care of a physician for management of an illness or condition?*

Yes

No

Q14

Please abide by the following Pre-care procedures Please check next to each entry :*

No Alcohol 24 hours prior to your appointment.

No Aspirin, Ibuprofen, Vitamin E, 24 hours prior to your appointment.

No Caffeine 24 hours prior to your appointment.

No strenuous workouts the day of your appointment.

No tanning the day of your appointment.

Please arrive at your appointment with no brow/face make-up. Eye make-up is ok.

No Botox in your brow area at least 2 weeks prior to your appointment

Q15

During the first 10 days after treatment, I WILL Follow the Aftercare below Please check next to each entry :*

Avoid direct exposure of the treated area to UV rays (Sun or Tanning beds)

Apply the provided aftercare ointment with a cotton swab every 2-3 hours or as needed. Do not use other products on the treated area other than what is provided to you.

No water, cleansers, creams, makeup, rough towels, and other products, etc... on the treated area.

Do not soak the treated area in water. You can shower as normal but keep the area out of the shower spray as much as possible. Do not let the area stay wet for more than a few minutes.

No baths, swimming, saunas, hot tub, steam rooms, hot yoga, etc....

Do not touch, rub, pick or scratch the treated areas. Let any scabbing or dry skin exfoliate off naturally. Picking can cause scaring.

Do not Remove or attempt to remove the pigment

Avoid heavy/excessive sweating

No facials, brow tinting, tweezing, waxing, threading

Avoid sleeping on your face

Visible healing will take up to 10 days, it is perfectly normal for your treated brow area to scab. The scabs will fall off within a few days. It is normal for the color to appear darker in the first couple of days, and then fade during the two weeks following the treatment.

Q16

For 4 WEEKS after my Treatment I will not have any of the following: Please check next to each entry*

Botox

Injectable Fillers

Chemical Treatments

Microdermabrasion

Q17

Signature*

Q18

Browtab Pre Appointment Intake Form -Form Fill