Permanent Brows Pre-consultation Form

Permanent Cosmetics Client Intake Form
Clients Legal Name*
Date of Birth*

MonthDayYear
Date
Drivers License No*
State of Issue*
City*
State*
Zip*
Phone*
Email*
example@example.com
How did you hear about us?
In case of emergency, notify (Name/phone number):*
Physician Name and Phone Number*
Confidential History
Are you currently using or taking (check all the apply):

Accutane/Isotretinoin within the past 12 monthsRetin-A/RenovaCigarettesPrescription Pain RelieversGlycolic, Beta or Alpha Hdroxy AcidsChemical PeelsSteroids or ImmunosuppressantsRetinols in Skin CareLatisse or lash/brow growth serumsAntibiotics within the past 2 weeksIndoor/Outdoor Tanning or Sunburn within the past 2 weeksHormone ReplacementBlood thinning medications or daily Aspirin useAny acne medications or Vitamin A derivativesContraceptivesMood altering medicationsContact Lenses
Confidential Health Information
Check all that apply

AnemiaTrichotillomaniaThyroid DisturbancesHIV / AIDSLiver DiseaseCirculatory ProlemsDiabetesHigh/Low Blood PressureHemophilia/Bleeding disorderHeart ProblemsSeizures or EpilepsyEczemaPacemakerCurrently Pregnant or NursingPsoriasisCurrent or Recent Cancer TreatmentsCold Sores/Fever BlistersRosaceaStaph/MRSAHerpes VirusKeloids (raised scars)GlaucomaAutoimmune disordersClaustrophobiaOcular HerpesHypo-pigmentation (lightening of the skin)Any problems healingDry eyesHyper-pigmentation (darkening of skin)
Additional details or other health issues not listed above
Are you under the care of a Physician or Dermatologist?*

YesNo
Are you required to take a course of antibiotics for any minor dental or medical procedures?*

YesNo
Do you have problems getting numb at the dentist?*

YesNo
List any medications supplements vitamins or herbs that you take regularly:
Do you have allergies or sensitivities to (check all that apply):

LatexProducts containing "-caine"MedicationsNickel or other metalsPetroleum productsFragrancesSkin Care or OintmentsEssential Oils
List all known allergies and reactions:
Have you received Botox/Dysport or fillers such as Juvederm/Restylane treatments in the past 30 days?*

YesNo
If yes, what areas?
Have you received a chemical peel, microdermabrasion, IPL, laser or other facial treatment in the past 30 days?*

YesNo
If yes, when?
Do you have previous or existing Permanent Brows?*

YesNo
Have you had any complications with previous tattoos or permanent makeup?*

YesNoI've never had tattoos or permanent makeup.
If yes, what complications?
Have you been advised by your doctor not to undergo any form of tattooing?*

YesNo
How often are you exposed to the sun whether during work or at play*
How often do you wear sunblock?*
What do you believe best describes your skin type? (check all that apply):*

DryNormalCombinationOilySensitive
Is there anything else we need to know about you in order to better service your needs?
Thank you for taking the time to complete this pre-consultation form. All of the information above is extremely helpful to provide the best care for you and ensure your safety during the procedure.
I understand that full disclosure of my past and current health history is in my best interest to ensure a safe procedure and that I have honestly disclosed such information initial*

Clear
I understand if I change my skin care routine or medications, or my health condition changes, I must inform the professional PRIOR to any service in the future.*

Clear
I understand that if I have health or medication contraindications the technician may require a written release from my Physician before proceeding with any procedure.*

Clear
Should be Empty:

Permanent Cosmetics Client Intake Form

Confidential History

Confidential Health Information