Consultation Forms

Client Consultation Form
CLIENT NAME*
Date*

MonthDayYear
Date
PERMANENT MAKEUP CONSULTATION
GENERAL INFORMATION
Full name*
Date of birth*

MonthDayYear
Date
Address*
Phone*
Email*
example@example.com
Gender*
Emergency contact name*
Phone*
Their relationship to you*
PERSONAL HEALTH HISTORY
Is this your first time receiving permanent makeup?*

YesNo
If ‘No’ what treatment did you have done?*
If ‘No’ when was your last treatment?*
Please list any of the following treatments you have had in the last year:
Skin GraftsLaser Hair RemovalBotoxLaser ResurfacingChemical PeelAHA/BHA ExfoliationAccutaneNoneOther
When was your last treatment?*
Do you have a history of any of the following medical conditions?

Alcoholism

Alopecia

Autoimmune disorder

Blisters/cold sores

Bleeding disorders

Cancer

Chemotherapy/radiation

Diabetes

Dermatitis (eczema)

Easy bleeding

Epilepsy

Psoriasis

Fainting episodes

Fever

Forehead/brow lift

Face lift

Haemophilia

Heart condition

Hepatitis (A,B,C,D)

High blood pressure

HIV positive

Keloid scarring

Liver disease

MRSA

Organ transplant

Shingles

Acne

Thyroid issues

Tumours, growths or cysts

Other

None
Answer:*
Are you taking any of the following medications?*
Have you had any reaction to the following?*

Lidocaine (anesthetics)Iron OxideEggsNone of the above
Are you taking any of the following medications/supplements?*

Prescription Blood ThinnersIbuprofenAsprinAdvilNonagonVoltarenIndocidPrenatal vitaminsVitamin ETopical Vitamin CGlucosaminePrimrose OilGingerFishoilPre workoutWeight loss medication/supplementsNone of the above
Are you pregnant or nursing?*

YesNo
Do you have any allergies? If ‘yes’ list below:*
Are you taking any blood thinners, including ibuprofen, Tylenol, aspirin, or fish oil? If ‘yes’ when did you last take your medicine?*
Do you use tanning beds or spend regular time in the sun?*
Have you ever had any adverse reactions to previous permanent makeup treatments? If ‘yes’ please describe below.*
Have you exfoliated or used any form of Retinoids in the last 72 hours? If ‘yes’ indicate method of exfoliation.*
Please list any prescription or OTC medications/supplements you are taking.*
What is your skin type?*
Signature*

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Client Consultation Form

PERMANENT MAKEUP CONSULTATION

GENERAL INFORMATION

PERSONAL HEALTH HISTORY