Permanent Makeup Client Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Preferred Pronouns*

How were you referred to us?*

Which of the following best describes your skin type? (Please check one)*

Type I - Fair skin tones (always burns, never tans)Type II - Light skin tones (burns easily, tans slightly)Type III - Fair to olive skin tones (burns moderately, tans moderately)Type IV - Light brown skin tones (burns slightly, tans easily)Type V - Dark brown skin tones (rarely burns, tans easily)Type VI - Dark brown to black skin tones (never burns, tans easily)

What permanent makeup service are you looking to have done?*

Have you had permanent makeup work done before?*

YesNo

If yes, when?*

Do you have any scars around the area to be treated?*

YesNo

Are you prone to keloid or hypertrophic scarring?*

YesNo

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or other Retinol/vitamin A derivative products?*

YesNo

If yes, please specify what and when last used:*

Do you wear corrective lenses?*

YesNo

Are you prone to cold sores or dry lips?*

YesNo

Have you experienced Botox, Restylane, or collagen injections?*

YesNo

If yes, which and how long ago?*

Have you had chemotherapy in the last 6 months?*

YesNo

Do you have any autoimmune conditions?*

YesNo

If yes, please list:*

Do you have any skin conditions? (ie. Rosacea, Sensitive Skin, etc.)*

YesNo

If yes, please list:*

What skin care products are you currently using? (List brands if known)*

Do you have any allergies to food, products, medications, topicals? (ie. Latex)*

YesNo

If yes, please list:*

Have you undergone surgery in the last 2 weeks?*

YesNo

Please list all vitamins, supplements, herbal remedies you take regularly:*

Please list all medications, including blood thinners, aspirin, ibuprofen, etc. you take regularly:*

Have you consumed any drugs or alcohol in the last 24 hours?*

YesNo

Have you consumed any caffeine in the last 24 hours?*

YesNo

What are you hoping to accomplish through permanent makeup?*

I declare that I am over the age of 18, not under the influence of drugs or alcohol, not pregnant or nursing, not on blood thinners or blood pressure medication, and am not an insulin-dependent Diabetic. I understand that many medications and some diseases and disorders may either contraindicate me for treatment or affect the results. I understand I should continue taking my medications, and tell my technician about all prescription and nonprescription drugs, supplements, topically applied products, eye drops, etc. that I use or take. I understand permanent makeup is a tattoo process; it is not an exact science, but an art. I have been informed of the general nature of permanent makeup and the specific nature of the procedure(s) described above.

Risks of Procedure(s): I understand there are risks associated with permanent makeup, including, but not limited to: Infection: Procedures which involve penetrating the skin could cause infection; Scarring: Recovery from the procedure(s) could lead to scarring; Allergic reaction: Pigments, dyes, or other materials used could cause a reaction; Color: Colors will vary based on skin tone, pigments may fade over time; Irregularity: Pigments may fan or spread, causing makeup lines to blur; Corneal Abrasion: Rubbing or scratching eyes or applying contacts shortly after an eyeliner procedure could cause an abrasion; Permanence: Permanent makeup is intended to produce long-lasting changes to appearance which may be difficult or impossible to modify or remove.

After reading through the following, please check next to each one to acknowledge:*

Signature*