Name Date
Date of birth Age FemaleMaleNB
Address
City State Zip
Phone Email
Emergency contact Phone #
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
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
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 had any facial or dermatology services in the last 30 days?NoYes
Have you recently done a chemical peel?NoYes If yes, when?
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
