PMU Client Intake & Model Form
Ombre or Nano Combo Brows
Are you filling this form as a client or a model?
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Client
Model
Full Name
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First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name & Phone Number
*
Have you had any previous brow procedures (e.g., microblading, shading, tattoo)?
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Microblading
Ombre Powder Brow
Nano Brows
Combo Nano Brows
Other
If yes, please specify the type and date of the previous procedure(s):
Which brow style are you interested in?
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Ombre Powder Brow
Combo Nano Brows
Other
Do you have any allergies? (e.g., latex, lidocaine, pigments)
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Yes
No
If yes, please list your allergies:
Please check any that apply:
Pregnant or Breastfeeding
Diabetes
Autoimmune Disorder
Epilepsy or Seizures
Blood Clotting Disorder
Heart Condition
Keloid Scarring
Skin Conditions (Eczema, Psoriasis, Dermatitis)
Accutane use within last 12 months
Chemotherapy within last 12 months
Botox or fillers in treatment area within last 2 weeks
Other
Are you currently taking any medications?
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Yes
No
If yes, please list your medications:
Please describe any relevant medical conditions or concerns:
I grant Dangesthetics full permission to use my photos and videos for marketing, education, website, and social media without compensation.
*
I agree (required)
I do NOT agree
Client Signature (please sign below to provide your consent)
*
Today’s Date
Continue
Continue
Should be Empty: