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Today's Date: December 22, 2025

Hello! Thank you for choosing Microblading San Antonio! Very excited to work with you! Please fill out this questionnaire. Its the best way to create an eyeliner treatment for you. 

Please note the following 

Eyeliner and/or permanent makeup treatments are not suitable for the following candidates: 

  • All potential clients under 18 years old
  • Allergic to local anesthetic or pigment
  • Any/All Auto-Immune Disorder (if you do not know if your condition is an auto-immune disorder please email microbladingsanantonio@gmail.com before booking as all deposits are non-refundable)
  • Cancer diagnosis (please email microbladingsanantonio@gmail.com for further discussion
  • Glaucoma (high eye pressure)
  • Uncontrolled high blood pressure
  • Any blood diseases (hemophilia, sickle cell anemia, platelet disorders)
  • Type 1 and 2 Diabetes
  • Current viral infection or an infectious disease
  • Any skin infection in the eyebrow area (including sunburn, skin rash, dermatitis, herpes simplex infection on the face, folliculitis)
  • Chemotherapy treatment in the last year
  • Currently on Accutane and/or Retin-A
  • Pacemaker, severe heart disease, and/or artificial valves
  • Prone to keloid scars
  • Epilepsy
  • Acute hepatitis
  • Leukemia
  • Sarcomas
  • Rheumatoid arthritis
  • Multiple sclerosis
  • Scleroderma
  • Pregnant and/or breast feeding
  • Allergic to the following ingredients: LIDOCAINE, TETRACAINE, EPINEPHRINE, ROSIN, GLYCERIN, HAMAMELIS VIRGINIANA EXTRACT, ISOPROPYL ALCOHOL, BENZYL ALCOHOL.


First Client’s Name
First Name*
Last Name*
Phone*
First Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
First Client’s Signature*
Second Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Third Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Fourth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Fifth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Sixth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Seventh Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Eighth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Ninth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Tenth Client’s Name
First Name*
Last Name*
Client’s Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Email Address
Email*
Confirm Email*
What do your eyes look like?
Please upload a picture of your eyebrows with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
ARE YOU CURRENTLY TAKING ANY OF THESE MEDICATIONS *
ACCUTANE/RETIN-A
LATISSE
BLOOD THINNERS
NONE
EYE CONDITIONS: *
Glaucoma
Cataracts
Macular Degeneration
Diabetic Retinopathy
Conjunctivitis (Pink Eye)
Blepharitis
Uveitis
NONE

LIST CURRENT MEDICATIONS (actual name or generic name of medication, please do not say "blood pressure medication" this is a general term and every medication has specific side effects) *
DO YOU HAVE AN AUTO-IMMUNE DISORDER? (If you suffer from an auto immune disorder you may not be a candidate for treatment, further questions, a doctor's note, and secondary waiver will be required. Please wait for email response after submitting this questionnaire) *
LUPUS
TYPE 1 DIABETES
RHUEMATOID ARTHRITIS (RA)
PSORIASIS/ PSORATIC ARTHRITIS
MULTIPLE SCLEROSIS
INFLAMMATORY BOWEL DISEASE (EX: CROHN'S DISEASE AND/OR ULCERATIVE COLITIS)
OTHER AUTO IMMUNE DISORDER
I DO NOT HAVE AN AUTO-IMMUNE DISORDER
OTHER MEDICAL CONDITIONS: *
PREGNANT OR BREAST-FEEDING
DIABETES
PRONE TO KELOID
PACEMAKER OR HEART PROBLEMS
UNCONTROLLED HIGH BLOOD PRESSURE
THYROID DISEASE (HYPO OR HYPER)
OTHER CRONIC DISEASES
NONE OF THE ABOVE
LIST ANY HEALTH CONDITIONS NOT LISTED *
LIST ANY ALLERGIES *
WOULD YOU HAVE HAD ANY OF THESE SKIN TREATMENTS IN THE 30 DAYS FROM YOUR POTENTIAL EYE LINER APPOINTMENT? *
MICRONEEDLING
BOTOX
MICRO-DERMABRASION
CHEMICAL PEELS
LASER RESURFACING
LASER SKIN REJUVENATION
FACIAL
FACE LIFT/PARTIAL FACE LIFT/ EYE LIFT/ ANY SURGICAL PROCEDURE FOR THE EYES
NONE OF THE ABOVE
HAVE YOU HAD PREVIOUS PMU ON OR AROUND YOUR EYES?*
No
Yes
WHEN? (IF YOU HAVE NOT HAD PREVIOUS WORK, USE TODAYS DATE) *
WHAT IS YOUR SKIN TYPE? SELECT ALL THAT APPLY *
NORMAL
DRY
COMBINATION
OILY
LARGE PORES
MATURE SKIN
SUN DAMAGED SKIN
WRINKLED SKIN

WHAT DO I WANT MY EYES/ EYE LINER TO LOOK LIKE? *

IF YOU HAVE PREVIOUS EYELINER OR PMU, BE AWARE THAT WORKING OVER OLDER WORK WILL NOT GIVE YOU THE RESULT YOU ARE LOOKING FOR. IT IS BEST TO EITHER COVER UP OR REMOVE. PLEASE DISCUSS BELOW TO BETTER ASSIT YOU *
What do your eyes look like? Please upload a picture of your eyes with no makeup and bright lighting! Once submitted we will make a recommendation and send a link for you to book!
  
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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