Your Full Name (required)
Your Address (required)
Your Email (required)
Phone Number (required)
What treatment are you interested in? (required)
Scalp MicropigmentationEyebrow TattooEyeliner TattooLip BlushTattoo LighteningLash Lift + TintBrow LaminationScar + Skin CamouflageStretch Mark CamouflageAreola + Nipple TattooAcneAlopeciaRadiation Marker
Date of birth (required)
Click which conditions apply to you. (required)
AllergiesKeloid ScarsDiabetesCold SoresIron DeficiencyAnemiaHemophiliaHypoglycemiaPregnant NowHeart ProblemAIDS (HIV)HepatitisCancerHigh Blood PressureAccutaneBlood ThinnerSkin Disorder/sMenopausePace MakerBotoxProne to faintingLip FillersCosmetic TattooMRI in the near futureNone
Current Medication (required)
Please upload a photo of the area of treatment (ie. face, body scar, stretchmarks - maximum file size 30MB)
*Important: Clients who experience cold sores are required to take cold sore medication (Valtrex) prior to having any lip treatments.
I acknowledge that any information contributed by me is true, to the best of my knowledge and that the present condition of the area that has been treated or will be treated is stated on this record.