Eyelash & Eyebrow Restoration

Evaluation Form

Have long, thick luscious eyelashes become an essential part of your look?

What is happening with your beauty routine right now, with your normal beauty clinics closed?

WE CAN HELP YOU ACTUALLY GROW YOUR OWN LASHES & EYEBROWS

—– LONGER – THICKER – DARKER —–

With a research backed medical solution to grow

(or regrow where have been lost through use of false eyelashes or over plucking of eyebrows etc)

or even if lashes or eyebrows have been lost due to medical conditions or medication.

—–

Simple apply our Elev8 Growth Serum once a day, at night before you go to sleep

WHICH BEST DESCRIBES YOUR EYE LASHES/EYEBROWS

Check all that apply you, or if None of those listed, please provide specific details: *

Not Thick enough

Not Long enough

Have ok Eyelashes/Eyebrows, but hairs are very fair

Have patchy eyelashes or eyebrows

My Eyelashes are noticeably thinner since using False Eyelashes

None of the above, but my Eyelashes/Eyebrows still need help!! (please provide details):None of the above, but my Eyelashes/Eyebrows still need help!! (please provide details):

What was the timeline for the above changes? *

Sudden

Gradual

Sporadic (no set pattern)

My Eyelashes or Eyebrows have thinned after taking medication/medical treatment

My Eyelashes or Eyebrows have completely fallen out after taking medication/medical treatment

Other (please provide details):Other (please provide details):

Are you currently using any products on your Eyelashes or Eyebrows *

Yes, I regularly have False Eyelashes professionally applied

Yes, I regularly apply False Eyelashes (myself at home)

Yes, I regularly Colour my Eyelashes/ Eyebrow

Yes, I have my Eyebrows waxed or threaded, plucked etc and have over-done/over-thinned in the past

Other (please provide details):Other (please provide details):

MEDICAL HISTORY

MEDHEAD ELEV8 EYELASH & EYEBROW GROWTH SERUM IS SAFE FOR MOST PEOPLE.

If however you have certain eye problems or other medical conditions or medication it may not be suitable for you, so please let us know if you suffer from any of the following:

Note to those who ticked yes for "Are you being treated for Ocular Hypertension and/or Glaucoma?" This does not exclude you from using Elev8, however may require monitoring

Have you had cancer/undergone chemotherapy? *

Yes (please provide brief detail):Yes (please provide brief detail):

Do you have HIV/immuno Supression Disease? *

Yes (please provide brief detail):Yes (please provide brief detail):

Any known Allergies *

Yes (please provide details of the allergy and reaction):Yes (please provide details of the allergy and reaction):

MEDICATIONS

Are you currently taking any medications to treat ocular hypertension and/or glaucoma? *

Yes (please provide details):Yes (please provide details):

The active ingredient in Elev8 lowers intraocular pressure, so if you are using IOP lowering medications for ocular hypertension and/or glaucoma, you must tell your eye doctor before you try Elev8, so that they can monitor your eye pressure.

Please provide details of any other prescription medications and dosage (if none, please state N/A) *

Please provide details of any supplements/non-prescription medications (if none, please state N/A) *

YOUR CONSULTATION BOOKING

Please advise your preferred contact method for your consultation: *

Skype

FaceTime

What is your Skype, Facetime or WhatsApp contact details *

My Consultation contact info is:My Consultation contact info is:

What time suits you best? (your consultation will take approx 10-15 minutes): *

Mid morning (10am - 12 noon ADST)

Lunchtime (12 noon - 2pm ADST)

Afternoon (2pm - 5pm ADST)

Late Afternoon (5pm - 6pm ADST)

Evening (6pm - 8.30pm ADST)

Other - please advise:Other - please advise:

DELIVERY ADDRESS (for delivery of your MedHead Elev8 Eyelash Regrowth Serum)

Street Address (including Apt# or Floor Level etc)

SUBURB

STATE

POSTCODE

Please include any other information not listed that you feel may be relevant (if none, please state N/A) *

If you would like to provide any supporting documents or images related to your issues, please upload here:

Maximum file size: 67.11MB