Custom Beaute - Permanent Cosmetics - with a Natural Approach

Forms

All 3 forms below must be filled out and signed prior to your procedure.  You can print them and bring them in, or fill them out at my office.





Medical History Questionnaire Online
If you are having your consultation on the same day as your procedure, please fill out the below online medical history questionnaire form so that I can review it prior to our visit.  These answers will not necessarily prevent you from having a procedure.
Client Name
Email Address
Date of Birth
Address
City
State
Zipcode
Cell Phone
Home Phone / Other
Physicians Name
Physicians Phone Number
Have you had a chemical peel within 6 months?
Yes
No
Do you bruise easily?
Yes
No
Do you routinely use any of the following?
Do you have any problems healing from small wounds?
Yes
No
Are you diabetic?
When is your next menstrual date if applicable?
Do you have darkening or lightening of the skin?
Hyper-pigment (darkening)
Hypo-pigment (lightening)
No
Do you tend to scar easily from minor injuries?
Yes
No
Do you have a tendency to faint or become dizzy?
Yes
No
Do you bleed excessively from minor cuts?
Yes
No
Do you consume aspirin daily?
Yes
No
Are you under treatment for depression?
Yes
No
Are you sensitive to petroleum based products?
Yes
No
If you have had permanent cosmetics, did you have trouble healing?
Yes
No
N/A
Are you undergoing radiation or chemotherapy treatment?
Yes
No
List any prescription drugs you are taking (and what they were prescribed for)?
Do you have any medical conditions that have resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure?
Yes
No
Do you have dry eyes or a tendency to water?
Yes, Water
Yes, Dry
Neither
Do you intentionally tan?
Yes
No
Do you have problems being anesthetized for dental procedures?
Yes
No
Check any Medical Conditions that you have...
Hepatitis
Sinus Problems
High or Low Blood Pressure
Glucoma or other Eye Disease
Stroke or Heart Attack
Cancer
Skin Sensitivities
Pacemaker
Botox Injections
Prosthetic Implants
Seizure Related Conditions
Keloid Scars
Lip Injections
Heart Conditions
Latex Allergies
Pregnant or Nursing
Cold Sores or Fever Blisters
Arthritis
Makeup Allergies
Heart Conditions
Auto-immune Disorders
Allergies to Skin Lotions
Oily Skin
Contact Lenses
Tobacco
Recreational Drugs
Alchohol Frequently
Metal Allergies
Permanent Makeup
Tattoos





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