Please fill out the form for the service you would like and then continue to the booking page to schedule your appointment.

Microblading

Request Microblading

Name *

Name

First Name

Last Name

Email Address *

Phone Number *

How would you like to be contacted for an appointment? *

Text

Date of Birth *

Date of Birth

YYYY

Are you currently pregnant or nursing? *

Yes

Have you ever had an allergic reaction to the following?

Check all that apply.

Lanolin

Latex/Rubber

Vaseline

Medications

Metals

Dyes

Lidocaine

Crayons

Glycerine

Foods

List any medications you have been taking over the last 6 months:

These can be contraindications to having the service performed. Please list everything for your safety and quality of service.

Have you ever had any of the followin?

Check all that apply.

Previous Microblading or other Permanent Makeup on the Brow Area

Trichotilomania (compulsive pulling out of the lashes or brows)

Diabetes

High Blood Pressure

Cancer

Hepatitis

Alopecia

Chemical/Laser Treatments (within past 6 weeks)

Fat Injections/Botox/Collagen Injections

Keloid Scar

Thyroid Disturbances

Epilepsy

How did you hear about Peachy Clean? *

Instagram

Google

Yelp

Referral

LocalFluence

Other

If you chose REFERRAL or OTHER, please include who referred you or your other method below:

Additional Comment/Questions/Concerns?

Please make sure you have read the FAQ. Many questions are addressed in there already.

I understand that it is my responsibility to read through ALL paperwork (including before/after care) emailed to me BEFORE my appointment and notify my technician of any contraindications or concerns that may prevent the service from being performed. *

I understand that failure to follow after care instructions provided by my technician may lead to loss of hairstrokes and/or color. *

I understand that microblading is a 2 part process and depending on the condition of my brows, the desired look may not be achieved until the enhancement session. * *

I understand that healed results vary for each client and that NO GUARANTEE will be made. One complimentary enhancement session is included with my initial payment and additional sessions may or may not require an additional charge at the discretion of my technician. *

I understand that my complimentary enhancement session cannot be completed until 6 WEEKS after my initial session to ensure the brows are completely healed. *

I understand that failure to cancel at least 48 hours prior to my scheduled appointment time could lead to the loss of my deposit and my rights to any promotional pricing. *

Thank you! You will be contacted in the next 24-48 hours to schedule an appointment. Please keep in mind that not everyone is a candidate for microblading.

Lash Lift

Name *

Name

First Name

Last Name

Email Address *

Phone Number *

How would you like to be contacted to schedule an appointment? *

Text

Please check any of the following that apply to you:

Skin Disorders

Inflammation of the Skin

Eye Disease

Eye Infections

Recent Eye Surgery

Blephartitis

Watery Eyes

Hay Fever

Allergies

Bell's Palsy

Precious Reactions to Eye Treatments

Contact Lenses

Allergy to Latex

Allergies to Adhesive, Glues, or Bonding Agents

Allergies to Acetone

Have you ever had any of the following?

Brow Tinting

Last Tinting

Lash Lift/Perm

Eyelash Extensions

Semi-Permanent Mascare

Did you have a negative reaction to any of these treatments?

Yes

If YES, which treatment?

Please provide details of the reaction:

Did you seek medical treatment from a doctor or specialist as a result of this reaction?

Yes

If YES, what advice or treatment did you receive?

Additional Comment

How did you hear about Peachy Clean *