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Make Payment
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Client Consent to be Photographed
Cancellation Policy and Deposit Agreement
HIPAA Form
Confidential Medical Profile
Consultation Photos
FAQ’s
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Contact Us
Forms
Confidential Medical Profile
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Occupation
Date of Birth
Phone Number
Gender
Male
Female
Non-binary
Are you over the age of 18?
Yes
No
Do you take fish oil?
Yes
No
Date Fish Oil Last Taken
Have you taken any mood-altering drugs in the last 12 hours? (i.e. Wellbutrin, Xanax, Prozac)
Yes
No
Do you have any history of cold-sores, herpes, or fever blisters?
Yes
No
Are you sensitive to Latex/Lidocaine/Epi?
Yes
No
Have you had a chemical or laser peel?
Yes
No
Date of chemical or laser peel
Do you have problems with healing?
Yes
No
Have you had any previous problems with tattoos?
Yes
No
Are you currently undergoing radiation or chemotherapy?
Yes
No
Are you currently taking any chemotherapy medications?
Yes
No
Are you currently using Retin-A or the like?
Yes
No
Date of last use of Retin-A or the like
Do you wear contact lenses?
Yes
No
Are you allergic to any metal?
Yes
No
Have you had any previous permanent makeup/microblading?
Yes
No
Have you had tattoos before?
Yes
No
Are you taking any medications including an immunosuppressive, such as anti-inflammatory or steroids?
Yes
No
Are you allergic to topical anesthetics?
Yes
No
Do you have a history of skin disease or remarkable skin sensitivities?
Yes
No
In the last year have you had a baby?
Yes
No
Which of the following applies to you?
Pregnant
Nursing
Don't know
None of the above
Are you required to take antibiotics during dental or invasive medical procedures?
Yes
No
Do you have any drug allergies?
Yes
No
If so, what are they?
What are the reactions?
Are you currently taking medication for high or low blood pressure?
Yes
No
Have you had frequent sun exposure or used tanning beds?
Yes
No
Have you consumed alcohol today?
Yes
No
Did you work out today?
Yes
No
Are you planning on any facial surgery in the near future?
Facelift
Eyelids
Brow lift
Other
No plans for facial surgery in the near future
What skin care do you use?
Do you have, or have you had, any of the following? Check all that apply.
Tuberculosis
MRSA/STAPH
Bleeding Disorder
On Blood Thinners
Trichotillomania
Eczema/Dermatitis
Allergies to makeup
Accutane treatment
Menopause/Run Hot/Frequent Hot
Alopecia
Keloids
Thyroid Issues/Meds
Stroke/Paralysis
Hypo-pigmentation
Heart Conditions/Pace Maker/Defibrillator
Shortness of Breath
Flashes
Hepatitis/HIV
Kidney Disease/Transplant
Liver Disease/Cirrhosis
Autoimmune Disorders
Epilepsy/Seizures
Refractive Eye Surgery
Smoker
Eyelid Surgery
Cataract Surgery
Lasik Surgery
Tear Duct Plugs
Glaucoma
Cancer
COPD
Take Vitamins
Have had a forehead/brow lift
Head Injury/Trauma (hit the head, accidents)
Organ Transplant
Rosacea (on the face)
Vitiligo
Use Lash/Brow Serum
Cold Sores
Herpes Simplex
Shingles (on face)
Ocular Herpes
Severely oily
Oily
T-Zone
Combination
Scar/s in the area to be done?
Botox
Other Medical Conditions/Surgeries
Alopecia Type
List Autoimmune Disorders
List Cancer
Date of Last Botox Injection
Please explain any checked question, list any other medical conditions or allergies, and list all your medications
Have you had COVID-19?
Yes
No
Have you had the COVID-19 Vaccine?
Yes
No
Signature
Clear Signature
Date / Time
Submit
COVID-19 SAFETY MEASURES FOR APPOINTMENTS
Please review our COVID-19 safety guidelines when booking your appointment!
Please Wear A Mask – We will have extra masks upon entry. All artists will be wearing masks during
treatments. We also ask that all clients wear their masks through the duration of their treatment, unless their
treatments involve their lips or facials.
DO NOT Bring Anyone With You – We ask that you please do not bring family, children or friends to the
appointment.
Sanitize Upon Entry – We will have hand sanitizer so you may sanitize before and after your appointment.
Limit Conversation – During this time, we ask for minimal contact and conversation to stop the spread of
COVID-19
Thank you for understanding and taking the proper measures in keeping everyone safe!
