First Name *

Last Name *

Email *

Telephone *

Address *

Skin (select all that apply)

Medications (select all that apply)

Allergies (select all that apply)

General Health (select all that apply)

Are you under a doctor's care?

Relationship Status

Have you taken any medications today

Do you have tattoos?

Have you had prior collagen induction?

Any prior permanent makeup?

Emergency Contact *

Emergency Contact Phone Number *

Physician Contact

Physician Phone Number

By checking this box I agree to share my health history. All information entered is accurate to the best of my knowledge. *

By checking this box I agree to the text above, and provide full consent and release for this procedure. *

Medical History Release