New Brow Client Questionnaire New Brow Client Questionnaire To help us serve you better, please complete all required fields of this New Brow Client Questionnaire prior to your appointment. New Brow Client Questionnaire First Name * Last Name * Phone * Email * Are you under 18 years old? * Yes No Are you pregnant or nursing? * Yes No Are you prone to or have keloid scarring? * Yes No Have you had any botox/filler (forehead and/or around eye area) in the last four (4) weeks? * Yes No Have you been using any Retinoid (retinol), AHAs/BHAs, Proactive or any product(s) containing an active ingredient in the last four (4) weeks? * Yes No Are you currently taking any medications, including antibiotics or immunosuppressants? * Yes No Have you used Accutane in the last 12 months? * Yes No Have you ever tested positive for HIV or Hepatitis? * Yes No Do you have any bleeding disorders? (ie hemophilia) * Yes No Are you diabetic? If yes, please contact us. * Yes No Do you have any autoimmune conditions which would keep you from healing normally? * Yes No Are you allergic to any anestetics and/or antibiotics * Yes No Are you currently taking any blood thinners? (ie Aspirin, Warfarin, Clopidogrel, Fish Oils) * Yes No Have you had any eye surgeries? * Yes No Are you able to take over-the-counter antihistamines? (ie Benedryl) * Yes No Do you have any of the following conditions? Check all that apply to you. * Epilepsy Fainting or Dizziness Tenderness Herpes HVB T.B. Eczema/Psoriasis Skin Conditions Fever Asthma Others None that you know of Preferred Pronouns * She/HerHe/HimThey/ThemOtherPrefer not to disclose What is your skin type? * NormalDryOilyCombinationAcne ProneNot Sure You would describe your pores as... * Large and mostly visibleSmall and mostly not visibleComboNot Sure How did you hear about us? * GoogleYelpInstagramFacebookFriend | Family | ReferralOther Do you have any existing cosmetic or body tattoos? * Yes No Let's connect by sharing your IG handle with us. Share with us the month and day of your birthday, we'd love to show our appreciation. Submit If you are human, leave this field blank.