Medical History Form | Natasha Brows

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Medical History Form

Please fill in the below form. If you have any queries, please get in touch.

First name

Last name

Email

Phone

Birthday

Day

Month

Year

Address

Please tick if the following applies to you:

Pregnant or nursing

Prescribed blood thinning medication

A history of keloid scars

Have received any cancer treatment in the past 5 years

Any HIV virus

Skin conditions such as eczema or psoriasis on the face

Autoimmune disease

An allergy to nickel

Heart disorders

Excessively oily skin

Have taken acne medication such as Accutane in the past 6 months.

Please share below a list of medication you currently take. If none, please leave blank.

Can we use your before and after images for marketing purposes?

Yes, no problem.

No, thank you.

If the consultation is missed without 48 hours notice, a fee of £50 will be payable. Please tick to agree to these terms.

Results vary from person to person and cannot be guaranteed.

We look forward to welcoming you in clinic and bringing you a step closer to beautiful, effortless eyebrows!

NatashaBrows

Proud Practitioner at Skin & Wellness, Alvechurch

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Thanks for submitting!

A proud practitioner of Skin & Wellness, Alvechurch

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