Client History Profile Form

*****READ THIS BEFORE STARTING THE ELECTRONIC HEALTH QUESTIONNAIRE*****

Prepare & take pictures of the area/body part you would like considered for permanent makeup. Ensure pictures are taken from all angles in a well lit environment so the technician can evaluate the procedure area. You will upload the pictures at the end of this questionnaire.

Prepare a list of all medical conditions you have & any medications/supplements/vitamins that you take. Towards the end of this health screening you will use the large space provided to list all medications, what they are prescribed/used for & how often they are taken. Add any health conditions or concerns that were not addressed. Do not forget to explain any "YES" answers in the space. Failure to follow these instructions may result in you having to redo the form to be considered as a client. Any information disclosed is only used to verify eligibility for cosmetic tattooing/micropigmentation at The Permanent Makeup Parlor. It is protected & will not be shared with any other party.

Today's Date*

Date

Name*

First NameLast Name

Date of Birth*

Must be at least 18 years of age on appointment date to receive permanent makeup services. (Virginia Law) Valid government identification will be copied on the appointment day before the procedure. The appointment will be cancelled/rescheduled without valid government ID.

Gender

Pronouns (optional)

Cell Number*

Please enter a valid phone number.

Home Number

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

Best time to contact you for questions or concerns:*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact*

First and Last NamePhone Number

Physician's Name

Physician's Number

How did you hear about The Permanent Makeup Parlor? *

Common answers: Instagram, Facebook, online ads, referral/word of mouth etc.

Are you pregnant or nursing?*

Have you ever had cold sores, herpes or fever blisters?*

Do you have any allergies to latex?*

Have you had a laser/chemical peel within the last six months?*

Have you ever had any permanent cosmetics or tattoos applied?*

Have you recently had any other skin treatments (microdermabrasion)?*

Do you bruise easily?*

Do you routinely use Retin-A, glycolic, AHAs (alpha hydroxy acids) or other exfoliating products?*

Do you wear contact lenses?*

Are you allergic or sensitive to any metals? (example: metals use for jewelry)*

Do you have any problems healing from small wounds?*

Do you use Lasisse or any other eyelash growth product?*

Do you use tobacco? If you use tobacco you may heal slower and this affects the timing for scheduling a touch-up appointment, if applicable.*

Do you have any heart conditions?*

Are you diabetic? If so, Type 1 or Type 2?*

Do you have any autoimmune disorders?*

Do you have any liver disease or dysfunction, such as Hepatitis?*

Are you sensitive or allergic to hand creams or body lotions?*

Do you have your lips injected with filler materials?*

Do you hyperpigment? (tendency to develop dark spots in the skin from wounds or the sun)*

Do you hypopigment? (lack of pigment within the skin)*

Do you tend to develop keloid or hypertrophy scars?*

Do you scar easily from minor skin injuries?*

Do you have any seizure related conditions?*

Do you have the tendency to faint or become dizzy?*

Do you bleed excessively from minor cuts?*

Do you have prosthetic implants?*

Do you consume aspirin daily?*

Are you under treatment for depression?*

Do you have a history of cold sores/fever blisters?*

Are you sensitive to petroleum-based products?*

Do you have Botox injections?*

If you have permanent cosmetics or tattoos did you have any problems with healing after they were applied?*

Are you currently undergoing radiation or chemotherapy treatment?*

Are you now or have you ever used the acne treatment, Accutane?*

Do you have an implanted cardiac device (ICD)?*

Do you take prescription drugs?*

Are you anemic?*

Do you have a history of skin sensitivities?*

Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure?*

Do you have problems with being anesthetized for a dental procedure?*

Do you have any known allergies or sensitivities to anesthetics?*

Do you have any allergies to topical make up?*

Do you have dry eyes?*

Do you intentionally tan, direct sun or tanning bed?*

Do you personally have any history of cancer?*

Do you have a history of stroke or heart attack?*

Are you allergic to colorants/dye?*

Do you have glaucoma or any other medical eye condition?*

Do you have arthritis?*

Do you have high or low blood pressure?*

Do you have sinus problems?*

Have you been diagnosed with HIV?*

Do you menstruate? if yes, please indicate the next date. Your skin is more sensitive around your cycle. Please schedule before or after expected cycle day to minimize discomfort.*

If you answered "YES" to any questions above, use the space below to provide an explanation. Correlate your explanations to the specific condition/issue.

List all medical conditions you have, all medications/supplements/vitamins you take, what each medication/supplement/vitamin is prescribed/used for & how often they are taken.

If this form has not addressed a medical condition/concern/issue you have, please list it below & provide an explanation.
If you have nothing to explain, please type "N/A"

A "YES" answer does not mean you are not a good candidate for permanent cosmetics. It may simply be information that is valuable to me as your technician as each person's body is unique, or it may indicate that based on any health conditions that affect healing, it would be advisable or require for you to consult with your physician before proceeding.

Failure to follow these instructions may result in you having to redo the form to be considered as a client. Any information disclosed is only used to verify eligibility for cosmetic tattooing/micropigmentation at The Permanent Makeup Parlor. It is protected & will not be shared with any other party.

USE THIS SPACE TO PROVIDE EXPLANATIONS*

Before your Appointment:

(Take a picture of these instructions)

DO NOT consume any alcohol 24 hours prior to your appointment.
DO NOT consume any caffeinated products 24 hours prior to your appointment. Caffeinated products include, but are not limited to coffee and coffee flavored items (including decaf), tea, pre-workout, energy drinks/pills, soda, chocolate, chocolate flavored items and certain chewing gums.
DO NOT take any blood thinning medication or fish oil supplements 24 hours prior to your appointment. Do your best to avoid consuming excessive amounts of garlic, ginger, cayenne pepper, black pepper, turmeric or cinnamon 24-48 hours prior to your appointment. These are natural blood thinners and can effect pigment retention and the healed results of permanent makeup.

Your signature indicates that you understand that all sales for permanent makeup services rendered at Permanent Makeup Parlor, LLC are final.

Your signature indicates that you understand that multiple sessions may be required based on results and there may be additional costs associated with any extra appointments needed based on healing.

Your signature indicates that you understand you must groom the brow hair and receive periodic color boosts to maintain the shape and color. Failure to maintain the shape and color will result in an additional charge to restore brows OR being charged as a new permanent brow service + color correction.

Type your full, legal name in the spaces provided. The name must match your valid government ID on the day of your appointment. *

First NameMiddle NameLast Name

Before and After photos are required to be taken for insurance purposes. Do you authorize The Permanent Makeup Parlor, LLC to use your photos for education, training & marketing purposes? (These photos assist with keeping the business running by providing a current portfolio for potential clients to review.)*

Upload pictures of the area/body part you would like considered for permanent makeup. Ensure pictures are taken from all angles, in a well lit environment so the technician can easily evaluate. *

Today’s Date *

Date

Signature*