Permanent Makeup: Client Intake

PERMANENT MAKEUP

CLIENT INTAKE FORM
Please complete all parts of this form. Your answers will help us better meet your needs and ensure that you have a happy and satisfying experience. All answers are treated in the strictest confidence.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*
Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Phone number*
Email*
example@example.com
Tick if you wish to opt out of receiving discounts and promotional offers
Occupation*
How did you hear about us?*
EyebrowsEyelinerLipsFrecklesBeauty MarkCorrection Work
What are you hoping to achieve with the procedure?*
For example: changes in shape, colour, fullness, greater balance, natural, bold
YesNo
If yes, please provide details *
i.e. where did you get the treatment, were you satisfied, did you experience any problems with healing, colour or retention etc.
If you've previously had Permanent Makeup on the area to be treated, please upload or take a clear picture of the entire area. You can also email it to hello@anhphan.co.uk for review.
Upload picture

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Take Photo
LIFESTYLE, CONTRAINDICATION & MEDICAL PROFILE
YesNo
YesNo
BotoxFillersChemical PeelsLaserFacial cosmetic surgeryNone
RetinolGlycolic AcidAlpha Hydroxyl Acid (AHA / BHA)Vitamin A/C derivativesOther exfoliating productsNone
YesNo
YesNo
YesNo
Smoke / use Nicotine productsRegularly consume caffeinated coffee / alcoholTake recreational drugsIntentionally tan in direct sun / sun bedNone
Bruise easilyHave problems healing from small woundsHave any skin sensitivitiesBleed excessively from minor cutsScar easily from minor skin injuriesTend to develop keloid / hypertrophic (raised) scarsTend to hyperpigment (darken) / hypopigment (lighten) when the skin is compromisedNone
YesNo
Please specify medication(s)
YesNo
Please specify
Topical / local anaesthetics (e.g. Lidocaine / Prilocaine numbing)Topical makeupPetroleum-based products (e.g. vaseline)Dyes (e.g. hair, lash or brow dyes and tints)Hand or body lotionsMetals (e.g. iron, nickel, jewellery)Essential / vegetable oils (e.g. lavender oil)Certain foodsNoneOther
High / low blood pressureSeizure related conditionsFainting, dizziness or blackoutsCancerStroke or heart attackHeart conditions / PacemakerLiver diseaseDiabetesAnaemiaAsthmaHormone imbalanceHIV / AIDSAcute or chronic eye condition e.g. glaucoma, dry eyes, corneal abrasions, cataractsThyroid conditionCold sores (Herpes Simplex)AlopeciaBleeding disorders e.g. HaemophiliaAuto-immune disorderHepatitis B / CLupusTrichlotillomaniaAcne / Dermatitis / Eczema / PsoriasisRespiratory infectionSkin infectionGastrointestina infectionEar or eye infectionBacterial, fungal or viral infectionNone
YesNo
Please provide further details to elaborate on all conditions you've disclosed or if there's anything else you think your technician should know:
i.e. specify if your ailments are current or occurred some time in the past, whether they are managed or under close supervision etc.
I acknowledge the importance of disclosing my accurate and complete medical history / condition, and that withholding medical information may be detrimental to my health and safety. I understand that if there is any change in my medical condition, it is my responsibility to advise my technician before every procedure. In the case where contra-indications are highlighted, I may need to provide a doctor's note to proceed with the treatment.
Full Name*
Signature*
Date*

DayMonthYear
By submitting this form you agree to be contacted by Anh Phan London regarding appointments, reminders, treatments and personal promotions from time to time. Your file will remain secure on our records via Jotform and in line with data protection, to ensure treatments can be delivered safely for a minimum of 7 years. Your data is ony used for internal processing by Anh Phan London and our business agents and will never be shared further. You can read our full Privacy Policy here.
FOR OFFICE USE ONLY:
- Office:
- Client Notes
- Skin Type
- Skin Condition
- Sun Reaction
- Fitzpatrick Scale Type
- Patch Test
- Client Record
- Should be Empty:

PERMANENT MAKEUP

LIFESTYLE, CONTRAINDICATION & MEDICAL PROFILE