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Health Form

Please check the questionnaire below to see if you are eligible for the treatments at Brow Works


Do you have previous Permanent Make Up? If yes when? __________________________________


Are you over the age of 18? Legal guardian’s initials _______


Have you had Botox or injectables? If yes when? __________________________________________


Have you had Aspirin or any blood thinning medications/supplements within the last 7 days? YES NO


Do you take Antidepressants or mood altering medication?


Have you had chemical or laser peel? If so when? _________________________


Do you have any problems with healing? YES NO


Do you have hyper pigmentation on healed scars? YES NO


Do you get fever blisters or cold sores? YES NO


Are you currently undergoing radiation or chemotherapy? YES NO


Are you currently using Retin-A or Alpha Hydroxyl skin care products? YES NO


Do you wear contact lenses? YES NO


Do you smoke? YES NO


Have you had caffeine products in the last 24 hours? YES NO


Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids? YES NO


Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or


Petroleum based products (Vaseline)? YES NO


Is there any history of skin diseases or remarkable skin sensitivities? YES NO


Are you pregnant or nursing? YES NO


Are you presently taking Vitamins A, E or fish oil in any form? YES NO


Are you required to take antibiotics before dental or invasive medical procedures? YES NO


Do you have any heart conditions? YES NO


Do you have any kind of allergies especially of makeup products and anaesthetics (lidocaine, prilocaine, benzocaine, tetracaine or epinephrine)? YES NO


Are you currently on Accutane Treatment for acnes? YES NO


Do you have Keloid or Hypertrophy Scars? YES NO


Do you have Hepatitis? YES NO


Do you have Diabetes? YES NO


Any tendency to bleed excessively from minor cuts? YES NO


Do you have Epilepsy/ Seizures of any kind? YES NO


Do you have any Autoimmune Disorders? YES NO


Do you currently or have you had Cancer? YES NO. If yes please explain  ___________________


Do you have HIV? YES NO


Please list any other medical conditions or allergies and medications below if any:



Services and course information:
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 +92 300 203 3080

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