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THIS FORM MUST BE COMPLETED BEFORE REQUESTING AN APPOINTMENT!

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Which procedure/s are you considering getting done?
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Eyebrows - Microblading
Eyebrows - Powder Brow
Eyeliner - Top only
Eyeliner - Top and bottom
Lip Blush
Are you pregnant or nursing?
No
Yes
Have you ever had cold sores of fever blisters? * Please note, if you are getting your lips done and get fever blisters, it is recommended that you get a prescription for Zovirax from your physician.
No
Yes
Do you currently have eyelash extensions? If you are considering getting Eyeliner done, these will need to be removed prior to getting the procedure done.
No
Yes
Do you have a Latex allergy? (We use nitrile gloves)
No
Yes
Have you had a Laser treatment or chemical peel on your face within the last 6 months? If so, when?
No
Yes
Do you use any Lash Serums? If you're considering eyeliner, discontinue use of lash serums for at least 3 weeks.
No
Yes
Have you ever had any permanent cosmetics or tattoos done?
No
Yes
Do you routinely use Retin-A, glycolic, or other exfoliating products? The use of these products HAVE to be discontinued for at least 4 weeks prior to getting procedure done.
No
Yes
Are you allergic or sensitive to any metals, for instance metals used for jewelry? If yes, pls list below.
No
Yes
Do you have Oily skin?
No
Yes
Do you use tobacco? If you use tobacco you may heal slower and this affects the timing of scheduling a touch-up appointment, if applicable.
No
Yes
Are you diabetic? If so, Type 1 or Type 2?
No
Yes
Do you have Auto-immune disorders? If so, pls note below.
No
Yes
Are you sensitive or allergic to hand creams/body lotions/cosmetic ingredients? If so, pls list known allergens.
No
Yes
Do you have your lips injected with filler materials? If so, when did you have it done last?
No
Yes
Have you had botox injections recently or are you planning on getting it done? If so, when did you have it done last?
No
Yes
Do you menstruate? If yes what is your next cycle date:
No
Yes
Do you hyper-pigment? (Tendency to develop dark spots on the skin from wounds or sun)?
No
Yes
Do you tend to develop keloid or hypertrophic scars?
No
Yes
Do you scar easily from minor skin injuries?
No
Yes
Do you have tendency to faint or become dizzy?
No
Yes
Do you bleed excessively from minor cuts?
No
Yes
Do you have any prosthetic implants?
No
Yes
Do you consume aspirin daily? If so, why?
No
Yes
Are you currently being treated for depression? If so, pls list medications.
No
Yes
Are you sensitive to petroleum based products?
No
Yes
If you have permanent cosmetics or tattoos, did you have any problems with healing after they were applied?
No
Yes
Are you undergoing radiation or chemotherapy treatment?
No
Yes
Are you now, or have you been on the acne treatment Accutane? If yes, explain below.
No
Yes
Do you have a pacemaker?
No
Yes
Do you take prescription drugs? Pls list below.
No
Yes
Are you anemic?
No
Yes
Do you have a history of skin sensitivities or skin conditions such as Eczema or Psoriasis? Please list below
No
Yes
Do you have any medical condition resulting in a medical professional requiring you to pre-medicate with an antibiotic prior to dental or other invasive procedures? Pls explain below.
No
Yes
Do you have allergies to makeup?
No
Yes
Do you suffer from dry eye?
No
Yes
Do you intentionally tan - Direct sun or tanning bed?
No
Yes
Do you personally have any history of cancer?
No
Yes
Do you have a history of stroke or heart attack?
No
Yes
To your knowledge are you allergic or resistant to over the counter level numbing products such as ELA-Max, Epinephrine, Lidocaine or Tetracaine?
No
Yes
Do you hypo-pigment? (Lack of pigment on the skin)?
No
Yes
Are you allergic to hair dyes?
No
Yes
Do you have glaucoma or any other eye disease?
No
Yes
Do you have arthritis?
No
Yes
Do you have high or low blood pressure?
No
Yes
Do you have sinus problems?
No
Yes
Do you have any type of hepatitis?
No
Yes
Your picture will be taken and edited to produce a before and after photo for Insurance purposes and our portfolio and social media sites.
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Agree
Pls refrain from Excercise, Alcohol & Caffeine the day of the service!
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Agree
Pls note that we have a very strict 48 hour cancellation policy and ask that you kindly respect our time:) We require a non-refundable deposit of $300 at the time of scheduling to secure your appointment.
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Agree
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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