Permanent Makeup Client Questionnaire
Please complete this form to help us ensure your safety and satisfaction with your permanent makeup procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you had permanent makeup procedures before?
*
Yes
No
Which area(s) are you interested in for permanent makeup?
*
Eyebrows
Eyeliner
Lips
Other
Do you have any allergies? (e.g., latex, anesthetics, pigments)
*
Yes
No
If yes, please list your allergies:
Are you currently taking any medications?
*
Yes
No
Please list any medications you are taking:
Please indicate if you have or have had any of the following conditions:
*
Diabetes
Heart Condition
Bleeding Disorders
Skin Conditions (eczema, psoriasis, etc.)
Autoimmune Disorders
Pregnancy/Breastfeeding
None of the above
Emergency Contact Name and Phone Number
*
Please share any additional information or concerns you would like us to know:
Client Signature (Please sign below to confirm your consent)
*
Submit Questionnaire
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