PMU_Client_Intake_Form_BeautyFull_by

Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address
Name
Phone Number
Format: (000) 000-0000.
Relationship
Other
Skin Type Oily Dry Combo Sensitive
Have you had any cosmetic tattooing before? Yes / No Do you use Retin-A, Accutane, or similar products? Yes / No Do you tan regularly or use tanning beds? Yes / No
Service Requested
Date of Procedure

MonthDayYear
Date
Technician
Please list any known allergies latex lidocaine pigments etc
Informed Consent & Liability Release

I understand the nature of the procedure and possible risks involved.

I release BeautyFull by Cynthia and its technicians of any liability.
Client Signature
Date

MonthDayYear
Date
Do you consent to before/after photos being used for portfolio/marketing? [] Yes [] No

I certify that the above information is true and correct to the best of my knowledge.
Signature
Date

MonthDayYear
Date
BeautyFull by Cynthia - Permanent Makeup Client Intake Form
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