Online Consultation Client Information Form

Name

First NameLast Name
Online Consultation Client Information Form

Permanent Cosmetics at EverlastInk Beauty, Inc.
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred by;
Please check which procedure you are interested in:

MicrobladingW-Brow / machine hair strokesOmbré brow/ soft powderEyelinerAquarelle LipsPermanent makeup removalPermanent makeup correction3D Areola Restoration TattooOther
PRE-PROCEDURE CHECK LIST; please read carefully and check all that apply to you, this will help us determine the when is the appropriate time to schedule your appointment, or if you need a medial clearance or pre-medication prior any treatment.

under the age of 18Pregnant or nursinghad Botox within the last 2 weeksAccutane Treatment within the last 6 monthsRetin-A or "Alpha Hroxy", Vitamin C peels in the last 2 weeksLaser/chemical peel within last 7 daysWaxing within 48 hoursEyebrow tinting within last 2 weeksTaking immunosuppresive medications, such as anti-inflamatory or steroidscurrently undergoing radiation or chemotherapy TXScarring (Keloids) or hyperpigmentationAutoimmune Disorders like LupusTaking Blood thinning medicationsSkin Irritation/ Skin diseasesHerpes Simplex (cold Sores) will require medication prior to Lip procedureHad previous Permanent Makeup proceduresLaser removal of permanent makeup within last 8 weeksWear contact lenses, only applicable for eyeliner procedureuse Latisse or any other eyelash enhancement product within last 2 weekshad Lasik or Cataract Surgery within last 3 monthsOrgan transplant, Joint replacement, heart valves, stents, pacemakerEyelash extensions (must be removed for eyeliner procedure)Active dermatological disorder, i.e. rosacea, eczema, psoriasisOther
Other concerns, Questions, please explain;
You can Submit Online by clickin "Submit" below. Your information is secure will go directly to EverlastInk Beauty, Inc.

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