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New Patient Registration Form
The patient agreement is a HIPAA requirement for your safety. If you have any questions Call Us and we'll walk you through the process. We're Here to Care!
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1
Image Field
This is a legal document. Please read carefully
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2
Client Name:
*
This field is required.
First Name
Last Name
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3
Birth Date
*
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-
Date
Month
Day
Year
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4
Age
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5
E-mail:
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6
Phone Number:
*
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Area Code
Phone Number
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7
Appointment Date
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Date
Month
Day
Year
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8
Address
*
This field is required.
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9
ID number
*
This field is required.
state id.
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10
Upload Photo ID
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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11
Upload Photo of Bare Brows
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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Natural Brow, NO Makeup added. Important for Coverups over other artist work.
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12
What are the main concerns relating to your eyebrows? What would you like to improve?
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13
What is the perfect shape, color, density, and thickness of your perfect brow?
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14
Concerns
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15
Are you 18 and older?
*
This field is required.
Yes
No
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16
Are you under the influence of drug or alcohol?
*
This field is required.
Yes
No
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17
Have you consumed Alcohol in the last 48 hours?
*
This field is required.
Yes
No
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18
FEMALE ONLY: Are you pregnant or nursing?
*
This field is required.
Yes
No
Other
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19
Do you have a communicable disease? if so describe below
*
This field is required.
FAILURE TO MAKE TECHNICIANS KNOWLEDGEABLE OF ANY BLOOD PATHOGEN TRANSMISSIVE DISEASES IS ILLEGAL AND WILL BE PROSECUTED
Yes
No
Other
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20
Skin conditions(e.g. rashes, eczema, infection, psoriasis, keloids, freckles, etc.)
*
This field is required.
If yes, please identify the conditions
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21
Are you currently taking any medications?
*
This field is required.
If yes, please list
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22
Any know allergies?
*
This field is required.
If yes, please list
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23
Have you ever had an allergic reaction to any of the following:
*
This field is required.
Latex
Vaseline
Hair Dyes
Lidociane
Rubber
Metals
Foods
N/A
n/a
×
Latex
Vaseline
Hair Dyes
Lidociane
Rubber
Metals
Foods
N/A
N/A if not applicable
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24
Have you ever had an allergic reaction to any of the following:
*
This field is required.
Latex
Vaseline
Hair Dyes
Lidociane
Rubber
Metals
Foods
N/A
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25
Medical History(e.g. Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
*
This field is required.
If yes, please identify the conditions
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26
Have you had a chemical or laser peel in the last six weeks?
*
This field is required.
Yes
No
Yes
No
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27
Have you had any alopecia AHA preparations in the last two weeks?
*
This field is required.
Yes
No
Yes
No
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28
Do you have any healing problems?
*
This field is required.
Yes
No
Yes
No
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29
Do you scar easily?
*
This field is required.
Yes
No
Yes
No
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30
Do you bruise or bleed easily?
*
This field is required.
Yes
No
Yes
No
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31
Have you ever seriously thought about hurting yourself?
*
This field is required.
Yes
No
Yes
No
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32
Have you previously had semi permanent make up done ? If yes, When? Also was it machine or manual?
*
This field is required.
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33
Old PMU Brow
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
previous artist work
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34
There is always a risk that tattoos can heal patchy and a different color from what has been used. this is out of our control and we cannot guarantee any results or how long they will last do you accept this risk ?
*
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35
Touch ups may be required we cannot say if you will need extra sessions. Your 6-8 week touch up is required. Are you happy to proceed knowing you may need extra sessions to get your desired result from microblading ?
*
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36
Microblading is a way of cosmetic tattooing, intended to be semi-permanent lasting average 12-18 months. On a rare occasion, the pigment may migrate under the skin. Please understand this is a risk which can happen although rare . Do you accept this risk?
*
This field is required.
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37
Please check below to confirm you have read and fully understand the following
*
This field is required.
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38
PMU Consent
*
This field is required.
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39
*
This field is required.
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40
Signature
*
This field is required.
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41
Date
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42
E-mail:
*
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