Nora Skin Spa - Permanent Makeup Form

Permanent Makeup procedure - client information form form

* Please fill out the required details below
If you have any remaining questions, please call us at (919) 671-7217.
Section I. Personal Information
Patient's Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Phone Number:*
Email:*
Gender:*

MaleFemale
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Address:*

Street Address Line 2
Primary Care Doctor:
Doctor City/State:
Occupation:*
For what kind of procedure you are applying?*

Eyebrows - Powder BrowsEyebrows - Nano HairstrokesEyes - EyelinerEyes - Lash EnhancementLips - Lip BlushLips - Lipstick EffectPMU Removal
Have you had permanent makeup before? if YES, describe what kind of and when. And if YES, did you have any problems with healing?*
Do you have diabet, HIV, AID, hepatits, cancer history, other illness and autoimmune disorders. Please list, even if some of them temporary (it doesn't mean that you will not get a procedure, just to provide double safety for you and for an artist)*
Put No if none
Are you pregnant or nursing*

PregnantNursingNot SureNo
Have you ever had cold sores or fever blisters?

Yes, oftenYes, very rearNo, never
Do you have eczema, rosacea, dermatitis or alopecia? Please specify:
Do you routinely use Retin-A, glycolic or other exfoliating products?
Have you done botox/filler recently last month?
Are you sensitive or allergic to hand creams, anesthetics, latex, mascara or anything else?
Are you taking any medications? please, specify.
Do you bleed excessively from minor cuts?

YesNoNot Sure
Your skin type more thin or thick?*

ThinThickI don't know
Please choose your type of skin*
What type is your face skin color? ( This provide us to understand type of The Fitzpatrick classification:

I Pale white skin, blue/green eyes, blond/red hair ----- Always burns, does not tanII Fair skin, blue eyes. ----- Burns easily, tans poorlyIII Darker white skin ----- Tans after initial burnIV Light brown skin ----- Burns minimally, tans easilyV Brown skin ----- Rarely burns, tans darkly easilyVI Dark brown or black skin ----- Never burns, always tans darkly
What color is your hair?
How did you hear about us? :) You answer will help us to build our marketing stronger! Thank you.*
Please take or upload pictures of requested face zone for procedure, with good light. Not required, but will help to consult you better.

Browse Files

Cancelof
AND the last question!!! Are you excited to have this procedure?

YesNo
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Submission Date

MonthDayYear
Date
Signature
Should be Empty:

Permanent Makeup procedure - client information form form