Name___________________________________________________________

Date of Birth ____________

Address ________________________________________________________________________________

Street ~ City ~ State ~ Zip

Home Phone _______________________________

Business Phone _____________________________

May we contact you at these numbers? __________

Referred by __________________________________________________________

Emergency Contact __________________________________________

Phone Number _________________

PROCEDURE(S) DESIRED:

_________ Upper eyeliner ________ Partial eyebrows ________  Lipliner

_________ Beauty Mark  _________  Lower eyeliner __________ Full eyebrows

_________ Full lip color __________ Scar Camouflage

__________  Other: _____________________________________

ALLERGIES: Check if you have ever had an allergic reaction to any of the following & describe what happened below:

________ Lanolin _______ Latex rubber _________ Bacitracin Ointment ________ Novocaine

________ Neomycin or polymyxin B ointment ________ Lidocaine ________     ________ PABA

________ Foods:__________________________________________________

Other allergies: ___________________________________________________

Reaction:________________________________________________________

EYES/EYEBROWS: Check all of the following that apply:

_______ Contact Lenses ________ Eye makeup sensitivities ______ Dry eyes

_______ Blurred Vision   ________  Thyroid abnormalities ________ Glaucoma

_______ Alopecia Universalis (total)   _______ Alopecia Areato (local)

_______ Other hair loss, describe: ____________________________

_______ Pull out lashes or eyebrows compulsively (Trichotillomania)

_______ Eyebrow tinting, date of last service:_____________

Other eye disorders: _______________

LIPS: Check all of the following that apply:

_______ Cold sores/fever blisters/herpes around the mouth.

  If yes, a prescription for Zovirax is required prior to any lip procedure.

_______ Collagen injections - location: _______________________

_______ Fat transfer injections - location: _____________________

_______ Gore-Tex implants - location: _______________________

SKIN: Check all of the following that apply:

_______ Any other tattoos - location _________________  

Age of tattoo: ________

Any problems _______

_______ Use of sunlamp/tanning bed/ suntan outdoors

_______ Are you currently tan in the area to be treated?

_______ Currently use Retin-A - location ________________________

_______ Currently using glycolic acid or other AHA skin products__________

_______ Have you ever had a chemical peel? When ______________

What type of peel _______________

_______ Do you have a scar you want camouflaged?

Age of scar: ________________________________

_______ Any keloid or hypertrophic scars - location: _____________________

_______ Bruise of bleed easily __________ Healing problems

_______ Other active dermatological disorders:

Describe:_____________________________________________________________

GENERAL MEDICAL: Check all of the following that apply:

_______ High Blood Pressure _________ Diabetes _________ Hemophilia or other clotting disorders

_______ Currently on blood thinners of anticoagulants such as Aspirin, Ibuprofin, Coumadin, Alcohol

_______ Mitral valve prolapse or valve implants _________ Heart Palpitations

_______Taken Accutane within the last 6 mos.

_______ Pregnant or nursing

_______ Ever had Hepatitis -When?___________________________

_______ Autoimmune disorders

_______ Seizures - Describe_________________________________

Please list surgeries:_______________________________________________________

If you are planning cosmetic or other surgery in the near future, describe:_____________________

List all medications, prescription and non-prescription, that you have taken in the last two weeks: __________________________________________________________________________________

If you are currently under a physician’s care for any condition, describe: ____________________________

Physician’s name: _________________

City: ___________________

Phone number: _______________

This history has been reviewed by the technician and my questions have been satisfactorily answered. I have also received and reviewed a copy of the Pre-Procedure Information Sheet and the After Care Sheet. I understand them and agree to follow them.

Signature__________________________________ Date: _______________

Copyright, Society of Permanent Cosmetic Professionals 9/95