Permanent Makeup Consultation Form
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Company Name
Procedure/Service
Microblading
Lip Blushing
Eyeliner
Scar Camouflage
Blush
Other
Choose an appointment date and time
Are you currently taking any medications?
Yes
No
What are the medications you're currently taking and what is their purpose?
Do you have any allergies?
Yes
No
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Are you wearing contact lenses?
Yes
No
Do you have any implants?
Yes
No
Do you have any Botox or other injectables?
Yes
No
Do you participate in outdoor recreational activities?
Yes
No
Please check below if you have the following medical condition:
Yes
No
Remarks
Cancer
1
2
Hyperpigmentation
3
4
Keloid
5
6
Hemophilia
7
8
Diabetes
9
10
Hepatitis
11
12
Tuberculosis
13
14
Epilepsy
15
16
Anemia
17
18
HIV positive
19
20
Cancer
21
22
Venereal Disease
23
24
Asthma
25
26
Iron Deficiency Anemia
27
28
Radiation therapy or chemotherapy
29
30
Eye Disorder
31
32
Skin Disorder
33
34
Herpes Simplex
35
36
Alopecia
37
38
Have you had micropigmentation before?
Yes
No
When did you have it?
-
Month
-
Day
Year
Date
Name of Beauty Clinic
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
TV Commercial
Online Ads
Posters/Banners
Magazines
Newspaper
Referral
Other
Acknowledgment
39
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.
Signature
Date
-
Month
-
Day
Year
Date
Submit
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