SMP/PMU CLIENT INTAKE FORM

SMP/PMU CLIENT INTAKE FORM
DATE

Month Day Year
Date
NAME
DATE OF BIRTH

Month Day Year
Date
ADDRESS
CITY, SATE, ZIP
PHONE
EMAIL
example@example.com
Emergency Contact Name and Phone
Medical History
1. Are you currently under the care of a physician?
Yes or No
If yes, please explain
2. Are you currently under the care of a dermatologist?
Yes Or No
If yes, please explain
3. Do you have an autoimmune disease?
Yes or No
If yes, please explain
4. Do any of the following conditions apply to you?

Cancer or Cancer Treatment Cold Sores Lupus Diabetes Herpes High Blood Pressure, beta adrenergic Arthritis HIV/AIDS Hepatitis Hormone Imbalance Psoriasis Eczema Thyroid Imbalance Blood Clotting Abnormalities Seizure Disorder Keloid Scaring Any Active Skin Disease/Skin Lesions Recent High Fever Iron Deficiency Frequent Swimming in Chemically treated pools Extreme stress Surgery on the Scalp in the last 4 months (120 days) Childbirth within the last 4 months (120 days) Heart Condition/Pacemaker Other
5. Do you have any other health problems or medical conditions? (Please List)
6. What medications or over the counter drugs are you presently taking? (Please check all that apply)

Birth Control Pills Hormones Antibiotics Steroids Vitamins/Herbs (please ist in other below) Other
7. Do any of the above medications make you photosensitive?
8. What other topical medications are you currently using?
Please list.
9. Do you need to take antibiotics or anti-viral medication prior to or after seeing your dentist?
Yes or No, and if yes, what.
10. Do you plan to undergo any scalp surgery or laser treatments?
Yes or No, if yes please explain
11. Have you ever had Scalp Micropigmentation done before?
Yes or No, and if yes when?
12. Do you form thick or raised sears from cuts or burns your scalp?
Yes or No, and if yes when?
13. Do you have hyper pigmentation (darkening of the skin) or hypo pigmentation or any marks after physical trauma?
Yes or No, and if yes, please explain
14. Are you pregnant?
Yes or No
15. Planning to become pregnant?
Yes or No
16. Are you using contraception?
Yes or No and if yes, what type?
17. Are you breastfeeding?
18. Have you ever had any allergie reaction to any of the following? (Please check all that apply)

Food Latex Aspirin Lidocaine, tetracaine, or other " caine" products Other
Describe the reaction you experienced
19. Which type of the following best describes your skin response to the sun? (Please check only ONE type)

Never Tans Always Burns Occasionally Tans Often Burns Often Burns, Tans Gradually Tans Gradually Burns Minimally Tans well Burns rarely, tans profusely (usually dark brown skin, black hair, and dark eyes) Never burns, deeply pigmented (black skin, black hair, and very dark cyes)
20. Which of the following best describes your skin type? (Please check only ONE type)

Normal Dry Sensitive Oily Combination Other
21. Please list all products/brands you are currently using on your face or scalp:
Moisturizer
Cleanser
Mask/Scrub
Topical Treatments/Meds
Sunscreen
Other
I voluntarily and honestly state that I have no known medical condition that might be by the service(s) or any medical condition that would prevent me from complying or following my technician and/or instructions or these warnings. I understand that answers may cause permanent harm to myself.
Please Initial
I am aware that it is my responsibility to inform the technician of my current medical or conditions. I agree to update this history, as a current medical history is essential for the to execute appropriate treatment procedures and have read and completed this client form in its entirety and provided truthful answers.
Please initial
I AGREE THAT BY SELECTING THE "SUBMIT' BUTTON, I AM SIGNING AGREEMENT ELECTRONICALLY. I AGREE YOUR ELECTRONIC SIGNATURE IS THE LEGAL EQUIVALENT OF YOUR MANUAL/HANDWRITTEN SIGNATURE ON THIS AGREEMENT.

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PRINTED NAME
DATE

Month Day Year
Date
SIGNATURE

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The PMU Client Intake template is for information and educational purposes only. If you have questions or concerns, you should seck the advice of a licensed attorney in your state.
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SMP/PMU CLIENT INTAKE FORM

Medical History