New Client Paperwork
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?
New Client Paperwork
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
1
2
3
Lidocaine/Tetracaine
4
5
6
Latex
7
8
9
Penicillin
10
11
12
Iodine (Ivp Dye)
13
14
15
Hay Fever/Sinus
16
17
18
Nickel
19
20
21
Hair Coloring
22
23
24
Codeine Or Demerol
25
26
27
Bee Sting Allergy
28
29
30
Makeup (Mascara, Etc)
31
32
33
Acrylate / Cyanoacrylate (Bonding Agents)
34
35
36
Adhesives (Tape, Cream, Mails, Etc)
37
38
39
Hyaluronic Acid
40
41
42
Other
43
44
45
Allergy History
Drug History
*
Current
History
None
Asprin
46
47
48
Ibuprofen
49
50
51
Thyroid Pills
52
53
54
High Blood Pressure
55
56
57
Heart Pills
58
59
60
Water Pills
61
62
63
Pain Pills
64
65
66
Blood Thinners
67
68
69
Insulin
70
71
72
Antidepressants
73
74
75
Acne Medication
76
77
78
Other
79
80
81
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.
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