Site Logotype

PERMANENT MAKE UP
CLIENT INTAKE FORM

    Client Information

    FemaleMaleNB


    Medical History

    Autoimmune DisorderAids/HIVBleeding DisorderCancerCardiac Valve DiseaseChemotherapyDepression/Mood disorderDiabetesEczemaEye surgery/injuryGlaucomaHemophiliaHepatitisHerpes/Cold SoresHistory of MRSAHypertronic Scarring/KeloidsKidney diseaseLiver diseasePregnant/breastfeedingPsoriasis/Dermatitis RadiationSkin conditionSerious Heart ConditionOther

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    Client History

    NoYes

    Have you ever had any of the following surgeries?

    NoYes


    NoYes


    NoYes


    NoYes


    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    By signing below, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition/s that would make the requested treatment unsuitable. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health

    Signature