CONSULTATION FORM

PERMANENT MAKEUP CONSULTATION FORM

Have you ever had a cosmetic tattoo or permanent makeup procedure before?

Do you have moles/raised areas in or around the treatment area?

Do you have or have you had a piercing in treament area?

Are you correnctly wearing lash extentins of any kind?

Have you experience Botox, Restylance or Collegan injections?

If so, pleae specify:

Do you scare easily?

Do you bruise/bleed easily?

Have you ever had an allergic reaction to any of the folloing?

What are your expectations and goals for the teatment? What would you like to improve/change abouot the area? Consider shape, color, density, thickness...

Any questions or concerns about the procedure?

By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to the waive all liabilities toward my technician and the employer for
any injury or damages incurred due to any falsification of my medical history

Permanent Makeup

CLIENT INFORMATION

Name:

Date:

Date of birth:

Age:

Address:

City:

State:

Zip:

Phone:

Email:

Emergency Contact:

Phone Number:

How did you hear about us?

Would you like to be added to our email list for news and exclusives offers?

MEDICAL HISTORY

Please mark any of the following conditions you may currently have.

Any known allergies?

List any medications you take regularly, including vitamins, herbal supplements, aspirin:

Any recent surgery, including plastic surgery?

Are you pregnant or trying to become pregnant?

Are you taking birth control?

Do you smoke or consume alcohol?

escosbeauty@gmail.com

734-417-6793

Website: www.escos.beuty.com

Permanent Makeup

PERMANENT MAKEUP CONSULTATION FORM

Have you ever had a cosmetic tattoo or permanent makeup procedure before?

​

What are your expectations and goals for the teatment? What would you like to improve/change abouot the area? Consider shape, color, density, thickness...

Any questions or concerns about the procedure?

By signing below, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to the waive all liabilities toward my technician and the employer for any injury or damages incurred due to any falsification of my medical history

Client Name ( Printed)

Client Name ( Signature)

Date

Page 2

escosbeauty@gmail.com

734-417-6793

Website: www.escos.beuty.com

By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to the waive all liabilities toward my technician and the employer for
any injury or damages incurred due to any falsification of my medical history