Online Consultation

Online Consultation

After completing this consult, please go ahead and proceed to online scheduling to schedule your visit!
Full Name*

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone #

Area CodePhone Number
Cell Phone #*

Area CodePhone Number
AGE: *
Referred By:*
Please note full name if referred by Friend or Family. If found via websearch - please specify!
Please mark all that apply.

I am Allergic/Sensitive to LidocaineI am Allergic/Sensitive to LatexI have been pregnant in the last 12 monthsI am currently pregnantI am currently BreastfeedingI am undergoing Hormone ReplacementI have a Thyroid conditionI frequent Tanning BedsI use exfoliating facial products dailyI wear contact lensesI am prone to Cold Sores/Herpes/Fever Blisters*I am taking prescription blood thinning medicationI have a bloodborne illnessI have uncontrolled high blood pressureI have had previous Permanent Makeup (IF YES, PLEASE USE LOWER SECTION TO TELL US WHICH PROCEDURE, HOW LONG AGO, AND EXACTLY HOW MUCH COLOR REMAINS)I am DiabeticI am currently using eyelash enhancing serums, or I have in the last 6 monthsI have been on Accutane in the last 12 months.I have had shingles on my faceOther
I am Interested in*

BrowsEyelinerLash EnhancementOther
Please List all Medications, Vitamins, and Supplements you regularly take. Certain medications can affect the healing and/or procedure itself. Please Include all prescription and over the counter medications.
Please use this comment box to tell us about any items listed above that may need a short explanation. If you marked that you have had your permanent makeup previously done, please let us know how long ago, which procedure, and how much color remains.
Additional Comments
If I have checked "yes" that I am prone to Herpes/Cold Sores/, I am required to consult with my Physician about anti-viral options before scheduling a LIP procedure. I understand that it is my responsibility and that I may be asked to show Physician Approval and/or Prescription prior to beginning my procedure. An outbreak during healing can disrupt the final result of my procedure, and this will not be the fault of the technician.

YesNoNot Applicable
Appointment Date if Already Scheduled:*
(remember, there is no need to wait to schedule after completing this form. Proceed to online scheduling or reach out directly with any questions or concerns.)
Please attach a BRIGHT, CLEAR, MAKEUP-FREE photo of your brows or eyeliner if you have previous permanent makeup. It is typically best to have someone else take the photo for you. Please do not send blurry photos.
Signature*

Clear
I have answered questions honestly and to the extent of my knowledge. I understand that not being forthright and honest with my medical history and background could negatively affect my procedure outcome. I agree to the policies of Elevate Cosmetics Idaho, available to me at www.elevatecosmeticsidaho.com. Clients who have had procedures performed by another technician will be charged the full price, according to the normal fee schedule, regardless of the procedure. We reserve the right to refuse any service or procedure.
Once completed please click on "SUBMIT FORM" below.

Your information will go directly to Elevate Cosmetics Idaho and you may then PROCEED TO ONLINE SCHEDULING to book your visit. No need to wait for a call first.

If needed, a technician will call you for additional information.
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