Permanent Makeup Consent

The Lash and Brow Lounge, LLC

Permanent Makeup Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Date

MonthDayYear

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number

Format: (000) 000-0000.

E-mail

History

Do you presently have or have ever had any of the following? Select all that apply:

List any allergies:

List any medications or vitamins you are currently taking:

Classify your skin type:

Are you currently seeing any other healthcare professional?

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Do you wish to waive the opportunity to have a patch test?

Check each box to ackowledge understsnding.

I give my permission to The Lash and Brow Lounge, LLC to use my photos for advertising. Some examples would include in portfolios, online, or in printed ads.