Client History Form Paramedical Artistry by Vanessa

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Preferred Phone Number For Voice Calling*
Can we leave a detailed message on his phone number?*

YesNo
Preferred Phone Number For Text
Please enter a valid phone number.
Can we leave a detailed text message on this number?

YesNo
Who referred you / how did you hear about Paramedical Artistry by Vanessa?*
Desired Procedure(s):*

Permanent EyelinerLiplineFull Lip ColorNipple / AreolaBeauty MarkSkin RepigmentationScalp MicropigmentationScar or Stretch Mark CamouflageTattoo CorrectionTraditional TattooOther
Have you ever had a cold sore? (If "Yes" and your desired treatment is lip liner or full lip color, you must contact your doctor for a prescription antiviral that prevents or minimizes herpes simplex virus on the area being treated.)

YesNo
Do you have moles or freckles on the part of the skin being treated? If yes, please explain.
Do you wear contact lenses?

YesNo
Are you currently under the care of a physician? If so, why?*
Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Do you take antibiotics before getting dental work?*

YesNo
Are you currently taking any prescription medication that thins the blood?*

YesNo
Please list ALL prescription or non-prescription medications your are currently taking.*
Are you pregnant or nursing?*

YesNo
Note On Payment, Deposits & Cancellations: A credit card and a $100 deposit is required at the time of booking for each appointment. Clients may pay the balance by card, cash, check, or venmo at the time services are rendered. Appointments may be cancelled with 48 hours notice without penalty. For cancellations with less than 48 hours notices, the $100 deposit will be charged / retained. For no shows and no notice, the credit care on file will charged the full price of the service scheduled and due.
By signing below, I certify that the information provided on this form is complete & I agree to the cancellation terms listed above.*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty: