Arawan Artistry Booking Forms

ARAWAN ARTISTRY AESTHETICSMedical Spa + Wellness Clinic ||

1431 McHenry Road, Unit 106, Buffalo Grove, IL 60089 || info@arawan.co || https://www.arawan.co || Clinic fax 847-221-6818 || Clinic landline 847-383-6217 || Clinic mobile phone 847-440-3417
PATIENT INTAKE AND REGISTRATION FORM

This intake form is a client discovery and consultation form that will help us learn about your health, physical, and social history to optimize your care. Answers are confidential, please respond thoroughly.
Name*

First NameLast Name
Date of Birth - service cannot begin without a valid photo ID for identity and age verification-Illinois State Law.*
Date Of Birth (month/day/year)
File Upload: Upload a valid photo ID (expired IDs are not valid)

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Email*
example@example.com
Mobile Number*
Format: (000) 000-0000.
Mailing Address*

Street Address

CityState / Province

Postal / Zip Code
Billing Address (if different from above)

Street Address

CityState / Province

Postal / Zip Code
In case of emergency who should we notify? How are you related?*
Full name and relationship
Emergency contact phone number*
Format: (000) 000-0000.
FACEBOOKINSTAGRAMGOOGLELinkedINOther
EmailTextAudio callVideo conferenceOther
Personal Health History

Please be accurate as your safety is our number one priority.
Full disclosure will assist in evaluating your healing process and does not necessarily prevent you from having an aesthetic procedure done.

To ensure that your procedure heals properly, we ask you to disclose the following conditions in this form.
Are you pregnant? When was your last menstrual period? *
If not applicable or no longer menstruating, please type "n/a". If on contraceptives, please indicate that. Your menstrual cycle may increase your sensitivity and decrease your pain tolerance. For body procedure, you may feel more bloated than usual.
Are you nursing or breastfeeding? *
Yes/No. If you answered YES, then, unfortunately you are NOT a good candidate at this time.
In case of a medical emergency, please provide the name and phone number of primary care provider (doctor, nurse practitioner, physician assistant) if you would like to share this information with us to share with the emergency medical team.*
Primary care provider name and phone number. If you do not wish to provide this information, please put "I refuse to share my primary care provider's information at this time."
I am losing hair. I am balding. My hair is thinning.I have receding hair line.My crown is beginning to have a light shadow.I have oily skin.I have dry skin.I have a combination oily and dry skin.I have back acne.I have dark armpits.I have very dark yellow to dark brown stained teeth.I have alopecia universalis.I have trichotillomania.My brows are thin and uneven.I want freckles.I have tattoos.I don't like my tattoo.I have acne scars.I have other scars from trauma or surgery.I don't like my scars.My lips shrunk and they have migrated from its original form.I would like to restore the shape of my lips.I want smoother, brighter skin, and enhance the absorption of skincare products.I have uneven skin texture and uneven skin tone.I want to reduce fine lines and wrinkles.I have "number 11" between my brows.I have crow's feet around my eyes.I have sunspots or brown spots on my face, arms, chest and back.I have small red dots on my skin.I have tiny red blood vessels in my nose.I have skin tags, milia, clogged pores, and black heads.I have a benign cyst that feels like a knot.I have visible deep lines in my neck, which is also known as "tech-neck."I have static wrinkle lines that are stuck and would not go away.I exercise at least 3 days a week.I try to exercise when I can, and my exercise routine is not consistent.I am overweight or suffer from obesity and have other health problems.I urinate often. I feel like I have a urinating problem.I leak urine when I cough. I dribble urine.I have a sensitive stomach. I rush to the toilet immediately after I eat.I have a low tolerance for pain. I need a lot of pain medication.I don't need a lot of pain medication. I have a high tolerance for pain.I am NOT afraid of needles.I drink caffeine daily.I drink alcohol daily.I drink hardly ever drink alcohol.I smoke cigarettes or vape.I smoke marijuana.I use cocaine or heroin.I have stretch marks.My stretchmarks bother me.I had a mommy make over.I am a breast cancer survivor.None of the above
I am 18 or over.I uploaded my photo ID.I guarantee that I am NOT pregnant and NOT nursing or breastfeeding.I have a skin condition such as psoriasis, vitiligo, or melasma.I am sensitive to topical anesthetics.I have a latex allergy.I am prone to keloid formation and I have evidence of keloid scarring.I have facial sunburn, facial psoriasis, eczema, acne, or keratosis in the target area for permanent make up or non-laser skin treatment.I have a transmittable blood disease.I have a history of hemophilia.I used Accutane within the past year.Melanoma is in my medical history.I have an active fungal, viral, or bacterial infection.I have unhealed wounds.I had bumps, pimples, or painful blisters on my lips before.I had a chemical peel 4 weeks ago.I had neurotoxin injections (Botox) 4 weeks ago in my desired area of treatment.I have frequent head aches (not migraines).I have a diagnosis of migraine head aches.I have a history of allergy to tattoo pigments or hair dye.I use a lash enhancing product such as Latisse.I have glaucoma.I had eye surgery.I had facial surgery.I have an autoimmune disease, take medications, or treatments that compromise my immune system.I have diabetes.I have a gall bladder disease.I have kidney or liver disease.I have vascular disease.I have abnormal blood pressure.I have a heart condition.I have a permanent pacemaker.I have other types of implanted device or implanted prosthetics (plastic, bone, or metal).I get short of breath easily.I sleep almost upright.My cholesterol is elevated.Thrombosis is in my medical history.I am on prescribed blood thinners (ex: Coumadin, Argatroban, Eliquis...)I take over the counter Aspirin.I take NSAIDS (Ibuprofen, Aleeve, Motrin, Ketorolac, etc...).I take vitamin E or fish oil.I had a transplant (kidney / heart / other), please explain below.I am in remission.I had radiation dermatitis.I had lymphedema.I have a history of communicable disease such as HIV and or hepatitis.I traveled outside of the country within the last 30 days.I currently have coughing, shortness of breath, or flu-like symptoms.I have a history of seizures or epilepsy.I have a history of fainting or narcolepsy.I have a history of osteoporosis or osteopenia.None of the above apply to me.
Please share anything else not mentioned above that's bothering you. Let us know when you started noticing the situation.
Please list your past medical and past surgical history (not indicated above) including any face surgeries or transplants or implants to help determine how these conditions may potentially affect the results of the treatment. Your aesthetic provider will advise you if medical clearance is required.*
Type “none” if not applicable.
List ALL current prescription and over-the-counter medications, vitamins or supplements you take, and the reasons you are taking them. Note: Vitamin E and Fish Oil increase bleeding and may reduce pigment retention for tattooing; therefore, stop taking 8 days before the procedure to allow the platelets to completely recycle. Some over-the-counter medications may increase skin irritation or sensitivity. *
Type “none” if not applicable.
Describe the skin type on your face: Oily, Dry, Combination of Both*
Type oily, dry, or combination.
What is your skin care routine? What type of skin care products do you use and what are they for? How frequent do you use these products? (Almost daily or almost never). Note: Retinol increases skin bleeding, stop taking 8 days before any aesthetic procedure. Anti-aging creams such as salicylic acid, and glycolic acid increase skin turn over rate and may cause fading or skin shedding faster. Please stop using anti-aging creams two to four weeks before the micropigmentation treatment on your face. And, keep your face hydrated with a hydrating cream that does not contain any acids. Hyaluronic acid also known as hyaluronan is a hydrating fluid that helps with skin health and wound healing and it is okay to use. *
Type “none” if not applicable.
Do you have a skin conditions or disease such as psoriasis, vitiligo, melasma, etc...? If yes, please indicate below. *
Yes or No. If yes, please describe.
Do you have any keloid scars? If yes, where? How did the keloid scar form? (Was the keloid scar from a surgical incision, traumatic injury, insect bite, etc...)*
Yes or No. If you answered YES, then you may not be a good candidate for this procedure.
For micropigmentation or tattoo lightening or removal: Do you currently have any tattoos or any previous restorative tattoo work? If yes to previous tattoo work such as eyebrows or this is a request for permanent make up correction, please indicate when you had the procedure done. Please send photos of the previous work done for an evaluation. Previous old tattoo work needing a color correction or color lightening will likely require additional time, labor, and materials. Additional sessions for color lightening or color correction is only fifty percent from the original cost.*
Type “none” if not applicable.
Allergies: Any known allergies? Are you sensitive to lidocaine, epinephrine, or any other topical numbing agents? List all allergies or sensitivities (including fruits, latex products, metal, etc…).*
Type “none” if not applicable.
Are you a breast cancer survivor who is interested in 3D areola tattoo service? When were you diagnosed with breast cancer? What type of breast cancer? What were your treatment modalities? When did you complete radiation and chemotherapy? Who is your oncologist and their phone number? When did you complete the breast reconstruction surgery? Who is your plastic surgeon and their phone number? *
If you are not a breast cancer survivor, please type "n/a" for not applicable.
Skin tagsKeratosisFollicular keratosis (pores that bump out like acne that may appear like chicken skin)Cherry spotsBrown sun spotsMorgan Freeman spots (Dermatosis Papulosa Nigra)Sebaceous hyperplasiaAcneMiliaBlackheadsClogged poresStretch marksScarsAcne scarsSurgical scarsRosaceaEnlarged poresDull-looking skin complexionHair lossUneven skin tone and texture (bumps and craters)Lost of elasticity (crepey skin)Fine lines and wrinklesExtra fat I want to get rid off such as a belly pooch, side handles, under arms, thighs, etc…Other
PHOTO REQUIREMENTS

Photos are helpful tools for evaluation to determine potential candidacy for the treatment you are looking for.  This step is required to assess the natural features of your desired treatment area in advance. Photos when indicated are required before an appointment reservation is confirmed.

1. If the initial photos are not clear, then additional photos will be requested.

2. If the photos continue to remain unsatisfactory for an evaluation, a free virtual consultation will be scheduled with you.

3. If the virtual consultation is still unsatisfactory, then we would request an in-person appointment.



3D Areola Tattoo | Belly Button  If you are here for a 3D areola tattoo or belly button tattoo, then you do not need to send a photo at this time. *But, send a photo of your pet (dog, cat, plant, etc...) to get through the required photo section below. If you like, please tell me their name in the "message" box below. I will take a screenshot photo of the target area during our virtual consultation and again before and after photos during the in-person appointment for documentation.

Other Micropigmentation Photo Requirements

1. Please upload a clear and well-lit photo of the target area, without camera filters, with and without makeup.

2. No side angles are necessary unless you would like an evaluation for a correction from someone's previous work.

3. Another photo with makeup will help. These photos should show the eyeliner style you like or the permanent lip color you desire.

4. Freckle Tattoos: Please take two photos. The first photo is a full-faced, well-lit photo without makeup. The second photo is a full-faced photo of how you would like your freckles mapped out.

5. Scar Camouflage: If the scar is not in a sensitive area, please send a well-lit photo of this scar. Please measure the size of the scar (length x width) and indicate that information in the "message" box below.

Hair and Skin Care Treatment Photo Requirement

1. Please send a clear and well-lit photo of the desired treatment area.

2. If you are requesting a body treatment for stretch marks, scars, and other types of minor skin irregularities, please measure the size of the surface area (length x width) and indicate that information in the "message" box below.
PHOTO REQUIREMENTS - Photos are helpful tools for evaluation to determine potential candidacy for the treatment you are looking for. This step is required to assess the current status of your desired treatment area in advance. Please ensure photos are clear and well-lit.*

You may upload as many clear and well-lit photos of the treatment area as you would like.
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Do you have any upcoming vacation travels or special events within the next 2-8 weeks? If yes, please describe the type of event and when it is scheduled, to be able to provide additional guidance on managing procedure healing process. *
Message to provider | Is there anything else you would like to share that was not captured above?
My signature represents that I read through the client discovery and consultation form. I give consent to Arawan Artistry Aesthetics to review this form and learn about me through the answers I provided. By signing below, I affirm that I have reviewed all the above statements and have been given the opportunity to ask questions. I hereby release Arawan Artistry, and its members, owners, employees, agents, and artists from any and all liability for any exposure or harm. *

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Arawan Artistry Aesthetics || Arawan MedSpa + Wellness

CLINIC ADDRESS: 1431 McHenry Road, Suite 106, Buffalo Grove, IL 60089

847-440-3417| info@arawan.co | https://www.arawan.co
GPS Directions, Arawan Artistry Studio: 1883 2nd Street, Highland Park, IL 60035
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ARAWAN ARTISTRY AESTHETICSMedical Spa + Wellness Clinic ||

Personal Health History