Your Full Name (required)

Your Email (required)

Your Instagram

Phone Number (required)

What treatment are you interested in? (required)
Scalp MicropigmentationEyebrow TattooEyeliner TattooLip BlushTiny TattooLash Lift + TintBrow LaminationScar + Skin CamouflageStretch Mark CamouflageAreola + Nipple TattooAcne Scar MicroneedlingWrinkle MicroneedlingAlopeciaRadiation Marker

Please Describe Your Goal or Area of Concern (example: I would like my knee scar camouflaged. I want stretchmarks on breast less visible. I would like my brows darker and more symmetrical.) *not applicable for tiny tattoos

Occupation (required)

Date of birth (required)

Gender/Pronouns (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 TattooUpcoming MRINone

Current Medication (required)

Referred By/How Did You Find Us?

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.

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