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New Client Form

Full Name *

Phone Number *

Are you over the age of 18? *

Yes

Date of Birth *

Select any that apply to you *

Autoimmune Disorders

Diabetes

Hepatitis

Heart Conditions

Pregnant or Nursing

Epilepsy

Cancer/undergoing chemotherapy or radiation

Taking antidepressants or mood altering medication

Taking blood thinning medication (including daily aspirin)

Accutane within the last year

Problems with healing or prone to Keloids

Tendency to bleed excessively from minor cuts

NONE OF THE ABOVE

Required

Please list any other medical conditions or concerns *

Do you have previous Permanent Makeup? If yes, when? *

Have you recently had Botox or injectables? If yes, when? *

Are you allergic to numbing agents such as lidocaine or epinephrine? *

Yes

Please list any known allergies or write "NONE" *

Sign your full name and date if you certify that all statements contained within this document have been read, understood, and answered accurately to the best of your knowledge *

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