Date
First Name
Middle Name
Last Name
Birth Date
Email Address *
Mobile Number *
Address (City) *
State *
Country *
Please submit a picture of your ID/Passport
Health Declaration
Client Eligibility Criteria Age Requirement: The client must be 18 years or older to proceed with the treatment. Identification: A government-issued ID must be presented to verify age and identity. Pregnancy/Breastfeeding: Clients who are pregnant or breastfeeding cannot undergo the procedure due to potential risks to both the mother and baby. Recent Treatments: Clients must not have had Botox or fillers on their face within the last 60 days, as this can affect the treatment results. Medical Conditions: Any existing medical conditions must be disclosed to ensure the treatment is safe for the client. Allergies: The client must inform the technician of any allergies to the products or materials used during the procedure.
Blood Conditions: Clients with transmittable blood diseases (e.g., HIV, HBV, HCV) are not eligible for the procedure.
Active Skin Cancer: Clients with active skin cancer in the treatment area cannot undergo the procedure.
Radiation/Chemotherapy: Clients currently receiving or planning to undergo radiation or chemotherapy are not eligible.
Skin Conditions: The presence of any skin diseases, rashes, or inflammation in the treatment area disqualifies the client.
Contagious Diseases: Clients with contagious conditions like Shingles or Chickenpox cannot have the procedure.
Post Inflammatory Hyperpigmentation (PIH): Clients with a history or current experience of PIH cannot undergo the procedure.
Skin Medications: Clients taking certain skin medications (e.g., Ro-Accutane, steroids) are not eligible.
Glaucoma/Diabetes/Hemophilia: Clients diagnosed with Glaucoma, Diabetes, or Hemophilia cannot have the procedure due to associated risks.
Heart Disorders: Clients with a history of heart disorders, heart attacks, or strokes are disqualified for safety reasons.
Epilepsy/Seizures: Clients with epilepsy, fainting spells, or seizures cannot undergo the procedure for safety concerns.
Healing Disorders: Clients with healing disorders that impair the body’s ability to recover are not eligible.
Cold Sores/Herpes (Lip Clients): Clients seeking lip procedures must not have active cold sores, fever blisters, or herpes outbreaks.
Have you done Botox or Filler in last 4 weeks?
Have you done Botox or Filler in last 4 weeks? *
Yes
No
Are you Allergic to Sesame Seeds ?
Are you Allergic to Sesame Seeds ? *
Yes
No
Please list any medical conditions, issues, or medications not listed above
Health Declaration
How many removal sessions done before? *
Has your skin undergone any procedures previously?
Please submit current picture of your Brows
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