Brow d'Luxe Client History Form

Name

First NameLast Name

Email

example@example.com

Date of Birth

Date

Gender

Type a question

Rows	Yes	No
Are you pregnant or nursing?
Have you had any alcohol in the last 24 hours?
Have you ever had cold sores or fever blisters?
Do you have allergies to latex?
Have you had a laser or chemical peel within 6 months?
Have you ever had any permanent makeup?
Have you ever had a body tattoo?
Do you have any problems healing?
Do you bruise easily for no obvious reason?
Do you routinely use Retin-A, glycolic, or other exfoliating products?
Do you wear contact lenses?
Are you allergic or sensitive to any metals, for instance metals used for jewelry?
Is your skin oily?
Do you use tobacco? If you use tobacco you may heal slower...
Do you have any heart conditions?
Are you diabetic? If so, Type 1 or Type 2?
Do you have any autoimmune disorders?
Are you sensitive or allergic to hand creams or body lotions?
Do you have your lips injected with filler materials?
Do you have botox injections?
Do you menstruate?
Do you hyper-pigment? (Tendency to develop dark spots on the skin from wounds or sun)
Do you hypo-pigment? (Lack of pigment on the skin)
Do you scar easily from minor skin injuries?
Do you tend to develop keloid or hypertrophy scars?
Do you have any seizure related conditions?
Do you have a 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?
Are you sensitive to petroleum based products?
Do you struggle to numb at the dentist?
Are you allergic or resistant to over the counter level numbing products that contain Epinephrine or Lidocaine?
Are you now or have you ever been on the acne treatment Accutane?
Are you wearing a pacemaker?
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 allergies to makeup?
Do you have dry eyes?
Do you intentionally tan - Direct sun or tanning bed?
Do you personally have any history of cancer?
Are you undergoing radiation or chemo-therapy treatment?
Do you have a history of stroke or heart attack?
Are you allergic to hair dyes?
Do you have glaucoma or any other eye disease?
Do you have arthritis?
Do you have high or low blood pressure?
Do you have sinus problems?
Have you experienced Hepatitis or Jaundice during the past 12 months?

If this form has not addressed a medical condition you have, please explain below:

If you answered "YES" to any questions above, please discuse with Artist before procedure. A "YES" answer does not indicate you are not an acceptable candidate for permanent cosmetics. It may simply be information that is valuable to 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 required for you to consult with your physician before proceeding.

Client Signature

Date Signed

Date