Permanent Makeup Consent

The Lash and Brow Lounge, LLC

Permanent Makeup Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Date*

MonthDayYear
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number*
E-mail*
History
Do you presently have or have ever had any of the following? Select all that apply:

History of MRSAHepatitis A, B, C, DAbnormal heart conditionDiabetesBotoxEye surgery, eye injury, or corneal abrasionForehead or brow lift procedureLip fillers/ Restalyne/ JuvedermChemical Peel within the past 30 daysBrow or lash tinting within the past 14 daysAccutane or any other acne treatmentSkin Care products containing Retin-A, glycolic acid, or alpha hydroxyEasy bleedingTaking blood thinners such as Aspirin, Ibuprofen, alcohol, coumadin, etc.AlcoholismContact Lenses in right nowTake pain meds before dental workDifficulty numbing for dental proceduresAllergic reaction to lidocaine, tetracaine, benzacaine, epinephrine, dermacaine, benzyl alcohol, vitaman ECurrently pregnant or breastfeedingAutoimmune DisorderCancerChemotherapy or radiationTumors, growths, cystsAllergic to any metal, food, etc.
List any allergies:
List any medications or vitamins you are currently taking:
Classify your skin type:
Are you currently seeing any other healthcare professional?
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Do you wish to waive the opportunity to have a patch test?
Check each box to ackowledge understsnding.
I give my permission to The Lash and Brow Lounge, LLC to use my photos for advertising. Some examples would include in portfolios, online, or in printed ads.

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Should be Empty: