Lift Artistry Preassessment Form

Lift Artistry Pre Assessment Form

Form MUST be submitted in order to book your PMU appointment
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Do you wear contact lenses?*
Any recent surgery (including plastic surgery)?*
Have you had any piercings, tattoos, or permanent cosmetics?*
Do you follow a restricted diet?*
Do you smoke?*
Have you had Botox in the last 8 weeks?*
Are you allergic to nail polish, and adhesives or hair dye?*
What is your stress level?*
Do you use any acne medication?*
Female Clients Only: Are you nursing?*
Do you experience any problems sleeping?*
Female Clients Only: Are you taking oral contraceptives?*
Female Clients Only: Any menopause problems?*
Female Clients Only: Are you pregnant or trying to become pregnant?*
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
Have you had a chemical peel or Microdermabrasion in the last four weeks?*
How frequently are you exposed to the sun or use a tanning bed?*
Have you used Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A or a derivative products in the last 3 months?*
Have you been under the care of a dermatologist or other medical professional within the past year?*
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
Have you had any of these health conditions in the past or present? Please check all that apply and provide additional information in the space provided:*

AllergiesEczemaPace MakerKeloid ScarringActive infectionMetal implantsInsomniaHeadaches (chronic)High blood pressureDiabetesAsthmaHeart problemSeizure disorderEpilepsySpinal injuryVaricose veinsArthritisCancerSkin CancerSkin disease/skin lesionsHormone imbalanceHysterectomyThyroid conditionPsychological treatmentBlood clotting abnormalitiesPoor circulationPhlebitisBlood clotsMetal bone pins or platesFrequent cold sores/Fever blistersSystemic diseaseLupusImmune disordersHIV/AIDSHerpesTBNONE OF THE ABOVEOther
Have you ever had an allergic reaction to any of the following?*

CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexNutsOther
Have you ever had an adverse reaction after using any skin care product? Choose 1 or more

RashIrritationPeelingSun SensitivityBreakoutOther
List your daily consumption of: Water ______________ Caffeine ______________ Alcohol ______________
Are there anything else you would like for us to know before booking your appointment ?
Consent for service: I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Consent for photos:I hereby grant permission and agree to allow Chidera / Lift Artistry to utilize any photos and videos of me taken for marketing and promotional purposes, including but not limited to online platforms, social media, print materials, and presentations.
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Lift Artistry Pre Assessment Form