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3D LASH & BROW
Salon & Academy

469 - 917 - 9305

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3D Lash & Brow Salon & Academy

Facial Consent Form

First Name

Email Address

Phone

Last Name

Address

DOB

Emergency Contact

Phone

Do you have any health problems or concerns that I need to be aware of before treatment, If the answer is yes, please describe?

Do you have any allergies?

Any recent surgery on your face, neck, and shoulders?

Are you currently, or have you used Retin-A, Renova, Resorcinol, or any powerful alpha hydroxyl Acids within the past 3 months?

Yes

If YES, please explain?

Are you using any other skin thinning products or drugs?

If YES, please explain?

Are you a diabetic?

Yes

Are you a diabetic?

Yes

Do you use a tanning bed?

Yes

Do you currently wear contact lenses?

Yes

Are you exposed to the sun daily or will you spend more time out in the sun anytime soon?

Have you experienced Botox, Restylane or Collagen injections?

Please select the following conditions you have/had experienced?

Pacemaker or pins in bones

Metal plate

Cold sores

Warts

Lupus

High/Low blood pressure

Cancer

Anemia

Epilepsy

Hepatitis

Asthma

Seizures

Stroke

Headaches

Pregnant

Easy bruising

Skin infections

Accident or trauma

I declare that the info I’ve provided is accurate & complete

Today's Date

Thanks for submitting!

469-917-9305

4230 LBJ Freeway, Suite 122

Dallas, Texas, 75244