Dusk Til Dawn PMU & Aesthetics Consultation Form

Name (please list legal name, must match ID and card payment if over 18)

Date

MonthDayYear

Date Of Birth

MonthDayYear

Address

Phone #

Phone number with area code firstFormat: (000) 000-0000.

Email Address

example@example.com

How did you find us?

Service:

Have you ever had an allergic or negative reaction to:

Describe your skin type as you see it.

What would you like us to focus on in your service today?

Are you currently using or recently used any of these methods of exfoliation?

Please list any products that come in contact with your skin:

Brand or product name also acceptable and encouraged to list.

Have you ever had a reaction to: (select all that apply)

Are you currently pregnant and/or nursing?

Have you ever been or currently prescribed medications for acne, PCOS, low estrogen, or high blood pressure?

Medications, their side effects and reason for being prescribed assist your skincare professional in choosing the safest and most effective service for you by having an accurate assessment of your skins particular sensitivities and needs.

Do you have a history of cold sores, fever blisters or Herpes Simplex 1 or 2 ?

Other

Is there anything of relevance to your appointment not included in this form?

Do you have any questions about a service you are interested in and need to be reached by the service provider prior to booking or the date of your scheduled appointment?

Please answer no if not, if yes, enter question in box

May I contact you via email/mail about future promotions and news? May I use media taken with your permission to advertise? (you may click more than one option)

How can we make you more comfortable?

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skincare professional from liability and I assume full responsibility thereof.

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