Permanent Makeup Beauty Consultation Form
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Procedure/Service
*
Brows
Lip Blushing
Lash line Enhancement
Are you currently taking any medications?
*
Yes
No
What are the medications you're currently taking and what is their purpose?
Do you have any allergies?
*
Yes
No
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
Please check all that apply:
Rows
Yes
No
Remarks
I am Allergic/Sensitive to Lidocaine
I am Allergic/Sensitive to Latex
I have been pregnant in the last 12 months
I am currently pregnant
I am currently breastfeeding
I am undergoing hormone replacements
I have a thyroid condition
I frequent tanning beds
I wear contact lenses
I am Diabetic
I am prone to Cold Sores/Herpes/Fever Blisters*
I am taking prescription blood thinning medication
I have a bloodborne illness
I have uncontrolled high blood pressure
I am currently using eyelash enhancing serums, or I have in the last 6 months
I have been on Accutane in the last 12 months.
Skin Disorder
Have you had any Botox or other injectables
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.
*
Yes
No
Not Applicable
How did you hear about us?
*
Please note full name if referred by Friend of Family.
Please upload a bright, clear, makeup free photo of your brows.
Acknowledgment
I understand that this procedure cannot guarantee 100% expected results.
I allow the center to take photographs for case review which is before and after.
I allow the center to use this photograph for a marketing campaign or advertising.
I release the center for any liabilities related to the treatment and result specifically allergic reactions and applied pigmentation.
I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.
I understand that permanent cosmetics are a form of tattooing.
I confirm that a healing period is required before the next or before the touch-up treatment.
I understand that this procedure might be painful and requires patience.
I understand that there might be an allergic reaction even though we do a skin test 24 hours before.
I understand that I might experience infection, minor bleeding, swelling, and redness.
I confirm that I have read, understand, and answered this consultation form accurately to the best of my knowledge.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: