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The Modern Artistry & Co.

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HEALTH QUESTIONNAIRE

Please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for the brow service procedures.

First Name

Email Address

Last Name

Date of Birth

Have you been in contact with anyone who had COVID or flu like symptoms in the last 14 days? *

Yes

Do you have any of the following symptoms: fever, cough, sore throat *

Yes

Do you suffer from any of the following diseases or disorders?

Hemophilia *

Yes

Allergies *

Yes

Diabetes Mellitus (Diabetes) *

Yes

Autoimmune Disases *

Yes

Heptatitis A, B, C, D, E, F *

Yes

Do you have Herpes? *

Yes

HIV + *

Yes

Infectious Diseases / High Fever *

Yes

Skin Diseases *

Yes

Epilepsy *

Yes

Eczema *

Yes

Cardiovascular Problems *

Yes

Are you taking any of the following medications?

Blood Thinners (Anticoagulants) *

Yes

Are you taking any medications on a daily basis? *

Yes

If YES, please specify:

Do you have a pacemaker? *

Yes

Do you have problems with healing wounds? *

Yes

Have you consumed drugs or alcohol in the last 24 hours? *

Yes

Did you in the last 14 days undergo surgery, in which you were exposed to radiation, or any other medical interventions? *

Yes

Are you pregnant or nursing? *

Yes

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Today's Date

I declare that the information I've provided is accurate & complete.

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CONTACT

CONTACT US

info@themodernartistryco.com

403.907.0890

lOCATION

THE BOUJEE BROW STUDIO + ACADEMY

5906 50 STREET

LEDUC, AB T9E 6P1

OPENING HOURS

Mon - Fri :

10am - 6pm

Sat:

11am - 4pm

Sun:

CLOSED

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