Returning Client Form
General Info
Are you a new or returning client?
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New Client
Returning Client
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
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Procedure Information
What type of service would you like to book?
*
Please Select
Nano/Powder/Combination Brows
Lip Blush Tattoo
Eyeliner or Lash Enhancement
3D Areola Restoration
When did you last receive this service from Shaneen?
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which appointment was it?
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First Session
Included (free) Touch Up
Additional Touch Up
Touch Up from Another Artist (first session)
Other
Please upload one or two reference pictures of yourself e.g. eyebrows, eyelids, lips, areolas. No makeup/filters and, if possible, in natural light.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Health Information
Check any of the following conditions or medications that apply.
*
Accutane
Antibiotics
Active dermatologic disorders ie. Rosacea, Eczema, Psoriasis, Shingles, Active HSV anywhere on the face
Bell’s Palsy
Blood Thinners (prescribed by a doctor, not aspirin)
Botox in the past 2 months
Exfoliants (retin-A, glycolic acid, vitamin c, etc.)
Heart Valve Replacement
Hemophilia
If you require pre-medication for dental procedures
Insulin Dependent Diabetes
Joint Replacement
Long Term Steroids
Lupus
Nursing
Organ transplant
Pacemaker
Pregnant or Breastfeeding
Receiving Chemotherapy or Radiation
Screws
Seizures
Stents
Steroids (long-term)
Tanning Beds
Titanium Rods
Under the age of 18
None
Please list all prescription medications you are currently taken or have taken in the last 6 months.
*
Do you have other medical conditions or anything else you think we should know?
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