Permanent Makeup Intake

Date

First Name

Last Name

Street Address

APT/ Suite

City

State

Zip Code

Phone

Date of Birth

Gender

Emergency Contact

Opt-in to receive information & offers

Yes

How did you hear about us? How did you hear about us?

Elite Spa may ask to scan a form of ID to keep in file and verify the accuracy of your information

General Information

Have you ever had a permanent makeup procedure before?

Yes

If yes, when?

Do you have moles and/or raised areas in or around the treatment area?

Yes

Do you have or have you had a piercing in the treatment area?

Yes

What would you like to improve/ change about the area? (Consider shape, color, density, thickness)

Have you used acne/ scar medications?

Yes

If yes, when and which drug?

Have you used Retin A within the last 6 months?

Yes

Have you used Cortisone within the last 6 months?

Yes

Have you used Acutane within the last 6 months?

Yes

Chemical or laser peel within the last 6 months?

Yes

AHA preparations within the last 2 weeks?

Yes

Do you bruise or bleed easily?

Yes

Date of last eyelash/ eybrow tint? if never done put NA

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Check any of the following if it applies to you

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Are you currently taking medications that thins the blood?

Yes

Are you currently under the care of a physician?

Yes

If yes, please explain

Physician contact information

Health Information

Do you have diabetes or any other autoimmune disease?

Yes

If yes, please specify

List any medications that you are currently taking (including over the counter)

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Do you have any of the following?

Musculoskeletal System

Osteoporosis

Tendonitis

Bursitis

Jaw pain (TMJ)

* If you suffer from any of the above, it is important that you notify your specialist, who can take the necessary precautions to ensure you receive the best possible treatment and to avoid any risk to your health

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For Female Clients

Are you taking any birth control pills?

Yes

If yes, Please specify

Are you on hormone- replacement therapy?

Yes

If yes, Please explain

Are you pregnant or breastfeeding?

Yes

Is there anything else that should be known before starting your treatment?

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I have read the above information and have given an accurate account of the questions. If I have any concerns, I will address these with my esthetician before the service. I understand that the services offered are not a substitute for medical care and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the therapist in giving better service and is completely confidential.

Full Name

Date

Signature

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