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Contact Information
Full Name*
First Name Last Name
Date Of Birth*
dd/mm/yyyy
E-mail*
example@example.com
Phone Number*
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
What other Beauty By Britt services are you interested in for the future?*
Permanent Makeup Microneedling Lash Extensions Skincare Treatments Spray Tan Henna Massage Teeth Whitening Bridal or Group Spa Sessions Lash Lift & Tint Other
How did you hear about us?*
Facebook Instagram Google Walk-in Friend or Family Referral Other
If referred, by whom?
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Medical History
Today's Date*
Month Day Year
Date
Please Answer If You Are:*
Taking Birth Control Pregnant Nursing None of the Above
Check All That Apply*
Dry Eyes Contact Lenses Glasses Corneal Abrasion Eye Drops Eye Allergies Glaucoma Visual Disturbances Allergy To Eye Makeup Light/Eye Sensitivity Eye Infections Accutane Trouble Growing Eyelash/Brow Hair Recent Eye Surgery Watery Eyes Do You Use Lash Growth Products None of the Above
Please List The Lash Growth Products You Use*
Check All That Apply*
Keloid Scarring Psoriasis Acne Retin-A Chemical Peel Treatments Allergies To Makeup Plastic Surgery Botox / Fillers Prior Tattoos Sensitive Skin Dermabrasion / Laser Rx Lupus Or Scleroderma Fever Blisters / Cold Sores Dental Problems Hyperpigmentation Tans Easily Tans Often Lesions Burns Easily Hypersensitivity Vasculitis Lines - Deep or Fine Scars Rosacea Autoimmune Disease Microneedling None of the Above Other
Please List Your Other Applicable Skin / Lip History

Allergy History*

	Current	History	None
Local Anesthetics
Lidocaine/Tetracaine
Latex
Penicillin
Iodine (Ivp Dye)
Hay Fever/Sinus
Nickel
Hair Coloring
Codeine Or Demerol
Bee Sting Allergy
Makeup (Mascara, Etc)
Acrylate / Cyanoacrylate (Bonding Agents)
Adhesives (Tape, Cream, Mails, Etc)
Hyaluronic Acid
Other

Allergy History

Drug History*

	Current	History	None
Asprin
Ibuprofen
Thyroid Pills
High Blood Pressure
Heart Pills
Water Pills
Pain Pills
Blood Thinners
Insulin
Antidepressants
Acne Medication
Other

List All Current Medications*
If none, write none
Which Side Do You Most Often Sleep On?*
Left Right Stomach Back
How Fast Do You Feel Your Hair Grows?*
Fast Slow Normal Rate Not Sure
Emergency Contact*
Full Name Relationship
Emergency Contact Phone Number*
Please enter a valid phone number.
Should be Empty:

New Client Paperwork

New Client Paperwork