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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:
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First Name
Ml
Last Name
Date of Birth:
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/
Month
/
Day
Year
Phone Number:
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Email:
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Gender:
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Male
Female
Ethnicity:
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Hispanic or Latino
Non Hispanic/Latino
Unknown
Prefer not to answer
Race:
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African American
American Indian
Asian
Caucasian
Native Hawaiian/Other Pacific Islander
Prefer not to answer
Other
Address:
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Street Address Line 2
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Primary Care Doctor:
Doctor City/State:
Occupation:
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For what kind of procedure you are applying?
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Eyebrows - Powder Brows
Eyebrows - Nano Hairstrokes
Eyes - Eyeliner
Eyes - Lash Enhancement
Lips - Lip Blush
Lips - Lipstick Effect
PMU 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?
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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)
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Put No if none
Are you pregnant or nursing
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Pregnant
Nursing
Not Sure
No
Have you ever had cold sores or fever blisters?
Yes, often
Yes, very rear
No, 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?
Yes
No
Not Sure
Your skin type more thin or thick?
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Thin
Thick
I don't know
Please choose your type of skin
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Dry
Very Dry
Oily
Acne
Mixed
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 tan
II Fair skin, blue eyes. ----- Burns easily, tans poorly
III Darker white skin ----- Tans after initial burn
IV Light brown skin ----- Burns minimally, tans easily
V Brown skin ----- Rarely burns, tans darkly easily
VI 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
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AND the last question!!! Are you excited to have this procedure?
Yes
No
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.
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