Permanent Makeup Intake Form
Preliminary Medical Info
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Please indicate if any of the following apply to you:
Currently pregnant?
*
Yes
No
Other
Breastfeeding?
*
Yes
No
Other
On blood thinners?
*
Yes
No
Other
Taken antibiotics in the last 7 days?
*
Yes
No
Other
Botox in the last 2 weeks?
*
Yes
No
Other
Use Retin-A/Retinol?
*
Yes
No
Other
Daily Aspirin regimen?
*
Yes
No
Other
Daily fish oil?
*
Yes
No
Other
Daily Vitamin E oil?
*
Yes
No
Other
History of cold sores/fever blisters?
*
Yes
No
Other
Submit
Should be Empty: