Name *

First Name

Last Name

Phone *

(###)

###

####

How do you prefer to be contacted? *

Phone

Email

Are you currently taking any blood thinning medications?(eg. Aspirin, Warfarin, Xarelto)? *

YES

NO

Do you have oily skin, particularly in the eyebrow area?(Skin that often appears shiny and makeup tends to slide off?) *

YES

NO

Have you ever had laser treatments on your eyebrows? *

YES - within the last 12 months

YES - within the last 5 years

NO

Do you currently have an eyebrow tattoo or permanent makeup? *

YES - it is very dark and heavily pigmented

YES - it is faded and light

NO

Are you pregnant or nursing? *

YES

NO

Do you have Diabetic Type 1 or 2 *

YES

NO

Do you have an allergy to nickel? *

YES

NO

Consent *

By submitting this form, I confirm that: The information I’ve provided is accurate to the best of my knowledge I understand that this is a preliminary screening and does not guarantee candidacy for Hyperrealism Nano Eyebrow tattooing. I agree to be contacted by Ink Tricks Cosmetic Tattooing for further consultation.

I agree and consent to the above