Permanent Makeup MEDICAL HISTORY
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Email *
Name *
Date of Birth *
Email *
Address *
Phone number *
Emergency Contact Name *
Emergency Contact Phone Number *
How Did You Hear about MT Brow Bar? *
Required
Who referred you?
I am over the age of 18 and not under the influence of any drugs or alcohol. (Place initials below) *
Desired Procedure? *
ANY previous permanent makeup, lash lift, last tint, brow lamination, brow tint or Henna services? (powder brows, microblading, etc) If so when? *
Previous work done by another artist is considered a correction or *new* powder brows/combo/nano and not eligible for a touch up or annual boost. I understand. *
Do you have any important events coming up? Wedding, honeymoon, vacation, surgery etc? Please explain and include date *
Allergies *
Please list ANY medications/supplements (especially fish oil, krill oil, turmeric, etc) you are taking. If none please state "none" *
General Medical. Select any that apply *
Required
Other medical history not mentioned in previous section
Skin *
Required
Please check any of the following that may apply to you: *
Required
Tanning Bed Use *
Do you spray tan *
Last spray tan
History of COVID? Date of last COVID illness? *
Recent facial surgeries? List below, including date/year
Any recent Botox, PDO Threads, Surgeries or Dermal Fillers in BROW region? If yes please explain below.
We recommend to reschedule after: Botox 6 weeks, Dermal Fillers 6 weeks, PDO Threads 8 weeks, Microdermabrasion minimum 4 weeks and surgeries in brow region 12 weeks
 *
Are you a fitness model/body builder?
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I also understand that I am required to have a consultation in-studio (unless MT Brow Bar deems a virtual consultation is fitting) PRIOR to any service appointment has been set.  PLEASE INITIAL *
I understand that I am required to submit a minimum of 3 photos of my brows without makeup to MTBB within 48 hours of booking my consultation OR 72 hours prior to my consultation (whichever is soonest).  Photos can be sent to 936-870-7021 or mtbrowbar@gmail.com *
I understand that this client questionnaire is required to be completed a minimum of 72 hours prior to my consultation (if possible).  Please initial below *
I understand that if I have a history of hyperpigmentation I am NOT a candidate for permanent makeup. *
I understand and agree to MT Brow Bar’s cancellation policy. Should I cancel within 48 hours my card will be charged $100. Should I no-show to my appointment my card will be charged 100% of the service price. *
Date *
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Sign Name Below *
A copy of your responses will be emailed to the address you provided.
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