Permanent Makeup Online Consult Form

Permanent Makeup Online Consult Form

SMUDGEPROOF INK & BEAUTY
Please read and answer all questions. This consult form is required to ensure that every single client is a good candidate for Permanent Makeup and will have the best results and experience! After submitting your form, you may pay your deposit (listed on the Service Menu). You will be contacted (based on preferred contact method on this form) if there is any further information needed and to finalize your appointment date/time. If you have not already done so, your deposit will be required at this time. Once you have completed this form, please return to my website and review the 'Policies', 'Pre-care and 'After-care' information. Thank You!*

I have read, understand and agree
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Preferred method of contact*

TextPhone callEmail
Age*
Were you referred by someone? please include their full name*
Mark all that apply?*

I am allergic to LatexI am sensitive to LidocaineI have been pregnant in the last 12 monthsI am currently pregnantI frequent tanning bedsI have used Acutane/acne medication in the last 12 monthsI am currently using a lash serum or have in the last 6 monthsI wear contactsI am taking blood thinnersI have high blood pressure that is not being managedI have unregulated diabetesI have had Botox/filler in the last 4 weeks (if yes, where) answer belowI have had previous Permanent Makeup (if yes, please list how long ago, which procedure, and how much color remains) answer belowNone of the above
If yes to Botox/filler in the last 4 weeks, please list area of the face and approximate date if possible. Type (NA) if this does not apply to you *
If yes to previous permanent makeup, please list how long ago, which procedure, and how much color remains. Type (NA) if this does not apply to you*
The procedure I am interested in is*

EyebrowsLipsEyelinerIn person consult
Please list any prescription/over the counter medications AND supplements that you are currently taking. Some medications/supplements may affect the healing process or procedure. Type (NA) if this does not apply to you*
If you checked that you are prone to herpes/cold sores, it is recommended to consult with your doctor about antiviral options before having a lip procedure. This is your responsibility to look into options beforehand and use proper aftercare. An outbreak can disrupt the healing process of a procedure and this will not be the technicians fault.*

I have read, understand and agreeI do not understand or agreeDoes not apply
Please attach a clear, unfiltered photo or your face/ procedure area (preferablly in natural light) I will ask for you to send another photo if the photo submiited is blurry or a filtered photo.
Upload here if not taking a photo. One or the other is required

Cancelof
Please select a date & time below that would work the best for you*
Please give two more dates & times that would work if your first choice is not available. I will contact you to schedule your final appointment date!
Date* Time*
Date* Time*
I agree to read and follow the pre-care and after-care instructions that will be provided by my technician (linked on technicians website). I understand that failure to do so can result in procedure being rescheduled or not healing correctly. I understand that my final results will be impacted by my willingness to follow these instructions and is not a result of my technician.*

I have read, uderstand and agreeI do not understand and agree
DATE*
Signature*

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