Permanent Makeup Consultation Form
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Procedure/Service
*
New Set of Ombré Powder Brows (no previous tattooing)
Ombré Powder Brow Reconstruction (existing tattooing)
Ombré Powder Brow Touch-Up (6-8 weeks after initial appointment)
Ombré Powder Brow Touch-Up (12+ months after initial appointment)
Ideal date range for service:
*
Are you currently taking any medications?
*
Yes
No
What are the medications you're currently taking and what is their purpose?
Do you have any allergies?
*
Yes
No
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
Are you pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Do you have any Botox or other injectables?
*
Yes
No
Do you participate in outdoor recreational activities?
*
Yes
No
Please check below if you have the following medical condition:
Rows
Yes
Remarks
Cancer
Hyperpigmentation
Keloid
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Cancer
Venereal Disease
Asthma
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia
Have you had cosmetic tattooing before?
*
Yes
No
When did you have it?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about us?
Facebook
Instagram
Word of Mouth
Google
Referral
Other
Referral Name
Acknowledgment
Type a question
*
I understand that this procedure cannot guarantee 100% expected results.
I allow the tattooist to take photographs for case review which is before and after.
I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.
I understand that permanent cosmetics are a form of tattooing.
I confirm that a healing period is required before the next or before the touch-up treatment.
I understand that this procedure might be painful and requires patience.
I understand that there might be an allergic reaction even though we do a skin test 24 hours before.
I understand that I might experience infection, minor bleeding, swelling, and redness.
I confirm that I have read, understand, and answered this consultation form accurately to the best of my knowledge.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Questions & Concerns
Submit
Submit
Should be Empty: