Lily's Beauty & Aesthetic || Permanent Makeup Client Consultation Form

Permanent Makeup Client Consultation Form

Date

Name

Surname

Address

Telephone Number

Age

Date Of Birth

Sex

Heart Disease

Cancer

Hircusiom

Pacemaker

Gold Injections

Diabetes

Burns/Grafter Skin

Herps

Aids

Liver / Kidney Disease

Scars

Epliepray

Port Wine Stain

Melanoma / Moles

Shingles

Haemangioma

Active Tan

Prioriasis

Polycystic Ovarian Syndrome

Anti-inflammatory Medication

Haemophilimia

Hormonal Imbalances

Acne

Vitiligo

Are You Currently Being Treated for a Condition Not Listed? If Yes, Please State.

Have You Had Botox Treatment In the Past 3 Months? If Yes, Please State.

Are you currently taking medication? Or contraception?

Have you ever used (or currently using) Retin A, Roaccutane or Glycolic Acid?

Have you had any laser treatment in the last 6 months?

Do you or have you suffered from any allergies?

Are you allergic to latex or vinyl?

Have you ever suffered an allergic reaction to topical numbing cream?

Doctors/ GP's Name

Doctors/GP's Address

Telephone number

Patient name

Client Signature

Date

If you have answered yes to any of the above questions the practitioner reserves the right to refuse any treatment if they test you are unsuitable or request confirmation this is ok from your GP.

Permanent Makeup Client Consultation Form

Permanent Makeup Client Consultation Form

Contact Info

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