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 *

Month Day Year
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date

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

History of MRSA Hepatitis A, B, C, D Abnormal heart condition Diabetes Botox Eye surgery, eye injury, or corneal abrasion Forehead or brow lift procedure Lip fillers/ Restalyne/ Juvederm Chemical Peel within the past 30 days Brow or lash tinting within the past 14 days Accutane or any other acne treatment Skin Care products containing Retin-A, glycolic acid, or alpha hydroxy Easy bleeding Taking blood thinners such as Aspirin, Ibuprofen, alcohol, coumadin, etc. Alcoholism Contact Lenses in right now Take pain meds before dental work Difficulty numbing for dental procedures Allergic reaction to lidocaine, tetracaine, benzacaine, epinephrine, dermacaine, benzyl alcohol, vitaman E Currently pregnant or breastfeeding Autoimmune Disorder Cancer Chemotherapy or radiation Tumors, growths, cysts Allergic 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 *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear
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.

Yes No
Should be Empty:

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