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Phi Brows Microblading

Pre Consultation Form

Date of birth? - (Must be over the age of 18)
Day
Month
Year
Sex
Are you happy for LADA to store your data so we can contact you:

Compatibility Questionnaire.

Please answer all of the questions below honestly to best of your knowledge. Don't worry if you answer yes to any of these questions, this doesn't mean you are ineligible for the treatment, we may just need some more information.

1. Are you currently pregnant/breast feeding?
Yes
No
2. Have you ever developed keloids or hypertrophic scars?
Yes
No
3. Have you had cancer or chemo/radio therapy in the last 3 years?
Yes
No
4. Do you have a medical diagnosis for any of the following: Epilepsy, Trichotillomania, Anxiety, Stress, Depression?
Yes
No
5. Do you have any active skin conditions on or around your eyebrows?
Yes
No
6. Do you suffer from any autoimmune disorders or other illnesses that affect the immune system?
Yes
No

For example: psoriasis, active eczema, lupus, vitiligo.

7. Do you have any blood disorders?
Yes
No

For example: Blood clots, Blood cancers, Hemophilia, Anaemia.

8. Do you have any infectious diseases ( HIV, AIDS, Hepatitis)
Yes
No
9. Are you currently or have you in the last 6 months finished a course of Accutane or Roaccutane?
Yes
No
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