Name Address Home/Cell PhoneEmail address Emergency ContactName Relationship PhoneAre you 18 or over? Yes No Have you had any aspirin or blood thinners in the past week? Yes No Have you ever had any permanent makeup procedures before? Yes No Do you have problems healing? Yes No Have you had a chemical peel, laser, forehead / brow lift, or facial fillers ? Yes No If so, last treatment date MM slash DD slash YYYY Previous problems with tattoos or has your physician advised you not to have a tattoo at this time? Yes No Do you smoke? Yes No Have you ever had a cold sore Yes No Are you allergic to any foods, metal, latex, antibiotics, sanitizers? If yes. please list: Yes No Do you presently have or previously had any of the following:History of MRSA Yes No Diabetes Yes No Hepatitis (A,B,C,D) Yes No Easy bleeding Yes No Alcoholism Yes No Face lift Yes No Abnormal Heart Condition Yes No Take meds before Dental work Yes No Brow or Lash tinting Yes No Autoimmune Disorder Yes No Oily Skin Yes No Cancer year Yes No Other Accutane or acne treatment Yes No Chemotherapy/ Radiation Yes No Tan by booth or sun Yes No Tumors/ Growths/ Cysts Yes No Difficulty numbing with dental work Yes No Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect. List Yes No Other Any diseases or disorders not Yes No Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl? Yes No FEMALE CLIENTS:Are you pregnant or trying to become pregnant ? Yes No Are you breastfeeding ? Yes No Are you using oral and / or hormone based contraceptives ? Yes No PLEASE CHECK ANY OF THE FOLLOWING THAT MIGHT APPLY TO YOU: Botox Fillers Brow Lift Face Lift Easy Bruising Easy Bleeding Chemical Peels Facials Brow/Lash tint Brow/Lash lift Tanning Spray Tan Difficulty numbing at Dentist None of the Above EmailThis field is for validation purposes and should be left unchanged.