Name

Email

Phone

Date of Birth

Service Requested Service Requested Ombre Powder Brows Ombre Powder Brow & Microblade Combo Lip Blush Lip Neutralization

Medical History (Check all that apply) Medical History (Check all that apply) Pregnant or breastfeeding Diabetes Autoimmune disorder Blood disorder Keloid scarring Skin conditions (eczema, psoriasis, etc.) Currently taking blood thinners Allergies (please list):

Allergy list (if applicable):

Ackknowledgement Ackknowledgement I understand results vary and are not guaranteed I understand healing is required I understand touch-ups may be needed I have disclosed all relevant medical information

Client Signature

Date