Permanent Makeup Consultation Form
Please fill out prior to appointment
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
Occupation
*
Company Name
*
Procedure/Service
Microshading (mix of Ombre & Microblading Hair Strokes)
Ombre Powder Brows
Lip Blushing
Blush
Other
Are you currently taking any medications?
*
Yes
No
What are the medications you're currently taking and what is their purpose?
Prepare for your Ombre eyebrow treatment with these simple steps:
No caffeine day of.
No alcohol 24 hours prior.
No blood thinners or painkillers within 24 hours.
No fish oil or vitamin E one week prior.
No filler or injections 3 weeks prior.
No chemical peels in brow area 2 weeks prior.
No antibiotics 2 months prior.
Do you have any allergies?
*
Yes
No
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
Are you pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Are you wearing contact lenses?
Yes
No
Have you had any Antibiotics in the last 2 months?
*
Yes
No
Other
Have you had Fillers in the last month?
*
Yes
No
Other
Have you had a chemical peel in the last 2 weeks prior to Brow Appointment?
*
Yes
No
Other
Please check below if you have the following medical condition:
Rows
Yes
No
Remarks
Cancer
Hyperpigmentation
Keloid
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Cancer
Venereal Disease
Asthma
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia
Have you had micropigmentation before?
Yes
No
When did you have it?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Beauty Clinic
How did you hear about us?
*
Facebook
Twitter
Instagram
YouTube
TV Commercial
Online Ads
Posters/Banners
Magazines
Newspaper
Referral
Other
Acknowledgment
Please read thorougly and checkmark
Checkmark each acknowledging policies and care.
*
I understand that this procedure cannot guarantee 100% expected results.
I allow the PMU artist to take photographs for case review which is before and after.
I allow the PMU artist to use this photograph for a marketing campaign or advertising.
I release the PMU artist 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.
I understand 100% for more results or to perfect any personal preferences for permanent makeup procedures I will need to schedule a 4-6 Week Touchup after Healing from the 1st initial session. I also understand I will have to pay for a Touchup weeks after and annually for personal preference.
I understand I can not add makeup/cosmetics to and around my new tattoo or this will cause a reaction and may affect the final results.
I acknowledge the healing process and steps to follow in order to get great results during healing period as well as healed period.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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