COSMETIKA INK Preliminary Intake Form for Permanent Makeup & Microblading

1
Name* This field is required.
FIRST
LAST
2
Email* This field is required.
example@example.com
3
Best Phone Number to Call/Text
AREA CODE
PHONE NUMBER
4
Which Procedure(s) Are You Interested In?* This field is required.Select all that apply
Eyebrows
Eyeliner
Lips
I'm just curious/want more info!
5
Please describe what exactly you are looking for, or what you do and don't like currently about your brows, eyes, or lips.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
6
Are You At Least 18 Years Old?* This field is required.Or will you at least be 18 years old at the time of your anticipated procedure?
YESNO
7
Which of the following applies to your personal medical history:* This field is required.PLEASE READ THROUGH THE LIST THOROUGHLY AND ANSWER HONESTLY -- IF YOU CHECK SOMETHING OFF, AND YOU BOOK A PROCEDURE, WE MAY BE CONTACTING YOU FOR FURTHER CLARITY TO ENSURE YOU ARE, IN FACT, A GOOD CANDIDATE FOR OUR PROCEDURES, AND/OR, WE WILL DIRECT YOU TO SPEAK WITH YOUR MEDICAL PROVIDER FIRST TO OBTAIN APPROVAL AND CLEARANCE
CURRENTLY PREGNANT
CURRENTLY NURSING
TYPE 1 DIABETES
LUPUS
HEPATITIS B/C
TUBERCULOSIS
HIV/AIDS
EPILEPSY
GLAUCOMA
CHRONIC DRY EYES
CATARACTS
OTHER EYE CONDITIONS/DISORDERS
ACTIVE/CURRENT SMOKER (of any substance)
ACTIVELY TAKING ANTIBIOTICS OR ANTIFUNGALS IN ANY FORM
HISTORY OF OR ACTIVELY UNDERGOING CHEMOTHERAPY
HISTORY OF OR ACTIVE CANCER, LEUKEMIA, SARCOMAS
ORGAN TRANSPLANT
BLOOD DISORDERS OF ANY KIND
UNCONTROLLED HIGH BLOOD PRESSURE
PACEMAKER
HISTORY OF HEART ATTACK OR STROKE
OTHER CARDIOVASCULAR DISEASES
HISTORY OF KELOID FORMATION
HYPERPIGMENTATION
SEVERE HISTAMINE REACTIONS OF THE SKIN
HISTORY OF COLD SORES/HERPES
HISTORY OF SHINGLES
HISTORY OF IMPETIGO
HISTORY OF DERMATITIS
ACTIVE ACNE AROUND THE AREA THAT WILL BE WORKED ON
VITILIGO
ROSACEA
PSORIASIS
ECZEMA
USE OF ACCUTANE (PAST OR PRESENT)
USE OF STEROIDS (PAST OR PRESENT)
HISTORY OF MRSA OR STAPH INFECTIONS
MOLES IN THE AREA WHERE THE PROCEDURE WILL BE PERFORMED
ALLERGIES OR SENSITIVITIES TO METALS OF ANY KIND
ALLERGIES OR SENSITIVITIES TO TITANIUM OXIDE, CARBON, OR ANY OTHER ELEMENTS/INGREDIENTS FOUND IN TATTOO INK AND PIGMENT
ALLERGIES OR SENSITIVITIES TO TOPICAL ANESTHETICS OF ANY KIND
ALLERGIES OR SENSITIVITIES TO ANY PRODUCTS THAT WOULD BE USED DURING THE PROCEDURE — FACE MAKEUP, SOAP, GREASE PENS/CRAYONS, ADHESIVE, WITCH HAZEL, ROSE OIL/EXTRACT, ISOPROPYL ALCOHOL, ETC.
NONE OF THESE APPLY TO ME
Other
8
Do you actively, or have a history of, picking/scratching/pinching at your skin, excessively pulling/plucking on your hair, or other BFRBs (body-focused repetitive behaviors)?* This field is required.We know this is a sensitive topic, and there is absolutely no judgment on our part. If you answer affirmatively of having BFRBs, this does not mean that we won't be able to work on you; we simply want to empower you with the best tools and resources to make sure your procedure is a success and let you know that we care and are willing to help. But we need to know this information upfront in order to prepare ourselves and you :)
YESNO
9
Please list any and all allergies and sensitivities you have (even if you think they are not relevant to microblading or permanent makeup).* This field is required.If you truly do not have any allergies or sensitivities, simply write "none."
10
Please list any medications, supplements, or vitamins you have consistently taken in the last 3-6 months* This field is required.If you truly do not take any medications, supplements, or vitamins, simply type in “none.”
Huge
Large
Normal
Small
Ok
Ok
11
Are You Wanting To Fix Old/Previous Microblading and/or Permanent Makeup?* This field is required.
YESNO
12
Do You Have Eyelash Extensions?* This field is required.
YESNO
13
Do You Have Moles or Other Raised Areas of Skin Directly On the Area Where the Procedure Will Take Place?* This field is required.We cannot work over moles or other raised skin located on your brows, eyelids, or lips -- so please keep this in mind if you still want a procedure done. We can somewhat work around these areas, but we cannot tattoo or microblade directly on/over them
YESNO
14
Do You Have A Lot of Blood Vessels or Capillaries Throughout Your Eyelids, AND/OR Translucent-Appearing Skin On Your Eyelids?* This field is required.Please be advised that if this applies to you, your eyeliner may not "take" as well as someone who has thicker skin and/or fewer surface-level blood vessels to the area.
YESNO
15
Do You Take Pain Relievers or "Pain Killers" (ex. Tramadol, Hydrocodone, Oxycodone, Percocet, etc.)?* This field is required.This is vital information in order for us to prepare ourselves and you on the anesthetic process and procedure, and how that may be different if you take these types of medications frequently or regularly.
Yes
No
Other
16
How Would You Describe Your Facial Skin?* This field is required.
Extremely Dry
Pretty Dry
Normal to Dry
Combination (oily in some parts, dry/normal in others)
Oily
Super Oily
Other
17
Is Your Skin Sensitive?* This field is required.Does your skin react easily and/or do you have to be cautious with the moisturizers, toners, face washes, etc. that you use?
Yes
No
I'm not sure
18
When Was the Last Time You Had Botox?* This field is required.
I've Never Had Botox
1 month ago or less
2+ months ago
Other
19
We Highly Encourage You To Attach A Photo of the Area You Are Interested In Getting Worked On. This Is Very Helpful For Us To Get A Quicker And Better Idea Of How We Can Help.
20
Have You Carefully Read Through Our Policies, Protocols, Restrictions, Contraindications, and Rules for Microblading/Permanent Makeup? * This field is required.It is your responsibility to read through our policies, protocols, restrictions, contraindications, and rules (all of which is posted on our website) and to make sure you are a suitable candidate for these procedures. Although we would love to fix all of the overplucked and destroyed brows from the 1990s, numerous conditions, medications, and other factors make many people ineligible for these procedures. Please review your medical history carefully and honestly!
Yes, I have read all of your Policies, Protocols, Restrictions, Contraindications, and Rules, and I CAN ATTEST THAT I AM 100% SURE I am an appropriate candidate for microblading and/or other permanent makeup procedures. I confirm that I will follow all instructions, guidelines, and restrictions that have been disclosed to me either via Cosmetika Ink's website, verbal communication, written instructions, text, email, phone call, in-person dialogue, other published website information, and/or any other modes of communication not here listed.
Yes, I have read all of your Policies, Protocols, Restrictions, Contraindications, and Rules, but I AM NOT 100% SURE I am an appropriate candidate for microblading and/or other permanent makeup procedures.
No, I have not read all of your Policies, Protocols, Restrictions, Contraindications, and Rules. I understand that it is my responsibility to do this to ensure I am an appropriate candidate for these procedures, and I have not yet read through this vital information. I understand that if I book a procedure without indicating that I have read the required information, then any non-refundable booking fee I have paid and any appointment time that I have requested/booked, will be forfeited and retained by Cosmetika Ink.
21
Do you want to schedule a free consult?* This field is required.After submitting your answers, we will review them and send you our booking link to schedule a free consult (they are usually 20 minutes long via phone or video call), if that is something you wish to do
Yes!
No thanks
No, I would like to schedule an actual procedure please (we will review your answers carefully and if you are deemed an appropriate candidate then a link will be sent to you to schedule an actual procedure; it is imperative that you are honest with the medical history you disclose to us, because we use this to determine if permanent makeup is appropriate for you)
Other
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