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

General Information

Please select your skin type
Have you ever had a permanent makeup procedure before?
Do you have moles and/or raised areas in or around the treatment area?
Do you have or have you had a piercing in the treatment area?
Have you used acne/ scar medications?
Have you used Retin A within the last 6 months?
Have you used Cortisone within the last 6 months?
Have you used Acutane within the last 6 months?
Chemical or laser peel within the last 6 months?
AHA preparations within the last 2 weeks?
Do you bruise or bleed easily?

Check any of the following if it applies to you

Are you currently taking medications that thins the blood?
Are you currently under the care of a physician?

Health Information

Do you have diabetes or any other autoimmune disease?

Do you have any of the following?

Head Neck
Musculoskeletal System
Skin & Infections
Other conditions
Any knows allergies
* 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

For Female Clients

Are you taking any birth control pills?
Are you on hormone- replacement therapy?
Are you pregnant or breastfeeding?
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.

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