Permanent Makeup Consultation Form
Date of Birth
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Choose an appointment date and time
Are you currently taking any medications?
What are the medications you're currently taking and what is their purpose?
Do you have any allergies?
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
Are you pregnant?
Are you breastfeeding?
Are you wearing contact lenses?
Do you have any implants?
Do you have any Botox or other injectables?
Do you participate in outdoor recreational activities?
Please check below if you have the following medical condition:
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Have you had micropigmentation before?
When did you have it?
Name of Beauty Clinic
How did you hear about us?
I understand that this procedure cannot guarantee 100% expected results.
I allow the center to take photographs for case review which is before and after.
I allow the center to use this photograph for a marketing campaign or advertising.
I release the center for any liabilities related to the treatment and result specifically allergic reactions and applied pigmentation.
I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.
I understand that permanent cosmetics are a form of tattooing.
I confirm that a healing period is required before the next or before the touch-up treatment.
I understand that this procedure might be painful and requires patience.
I understand that there might be an allergic reaction even though we do a skin test 24 hours before.
I understand that I might experience infection, minor bleeding, swelling, and redness.
I confirm that I have read, understand, and answered this consultation form accurately to the best of my knowledge.
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