Client Information Name Date Date of Birth Age FemaleMaleNB Address City State Zip Phone Email Emergency contact Emergency Contact Number How did you hear about us? Would you like to be added to our email list for news and exclusive offers? YesNo
Medical History Do you have or have you had any of the following conditions? If yes, please select them: Autoimmune DisorderAids/HIVBleeding DisorderCancerCardiac Valve DiseaseChemotherapyDepression/Mood disorderDiabetesEczemaEye surgery/injuryGlaucomaHemophiliaHepatitisHerpes/Cold SoresHistory of MRSAHypertronic Scarring/KeloidsKidney diseaseLiver diseasePregnant/breastfeedingPsoriasis/Dermatitis RadiationSkin conditionSerious Heart ConditionOther Have you ever had an allergic reaction to latex?NoYes Have you ever had an allergic reaction to antibiotics?NoYes Do you have any other allergies?NoYes If yes, what kind of allergies do you have? List any medications/supplements you are currently taking Have you taken any of the following in the last 2 days: Aspirin, Ibuprofen, Coumadin, Alcohol?NoYes If yes,Please specify Do you wear contact lenses?NoYes Do you often have eye irritation, itching or watery eyes?NoYes
Client History Have you had any permanent or semi-permanent makeup services done before?NoYes If yes, what kind of permanent makeup did you do? Have you ever had any of the following surgeries? Blepharoplasty (eyelid surgery)NoYes If yes, when? Forehead / brow liftNoYes If yes, when? Lasik eye surgeryNoYes If yes, when? Have you recently done a chemical peel?NoYes If yes, when? Have you had any facial or dermatology services in the last 30 days?NoYes Are you currently wearing lash extensions?NoYes Do you have a tanned/sunburnt skin?NoYes Have you used Latisse or any eyelash/eyebrow growth conditioner within the last 2 months?NoYes Have you received Accutane (acne medication) within the last year?NoYes Have you received Botox, Lip fillers, Restylane, Juvederm or Collagen in the last 6 months?NoYes Have you used Retin-A, Renova, AHA, BHA, Retinoid or Retinol products in the last 3 months?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