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*
Format: (000) 000-0000.
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
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
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
YesNo
YesNo
YesNo
List any medications supplements vitamins or herbs that you take regularly:
LatexProducts containing "-caine"MedicationsNickel or other metalsPetroleum productsFragrancesSkin Care or OintmentsEssential Oils
List all known allergies and reactions:
YesNo
If yes, what areas?
YesNo
If yes, when?
YesNo
YesNoI've never had tattoos or permanent makeup.
If yes, what complications?
YesNo
How often are you exposed to the sun whether during work or at play*
How often do you wear sunblock?*
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