Permanent Make-up

Today’s Date:

Birth Date:

Name:

Home Phone:

Work Phone:

Employer:

Occupation:

If yes, please provide Physician’s Name, address and phone number.

Person to contact in case of an emergency:

Name:

Phone No.

List all medication you are currently taking, including Retin-A, Glycolic Acid and Acutane:

List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams):

Have you recently undergone a skin peel?

What products do you use for skin care?

When was your last eye exam?

Examining Physician:

Signature

Date

PRE-TREATMENT ADVICE AND PROCEDURES

Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear “crusty” for up to one week.
Please wear your normal make-up to the procedure. If you are having lips or brows done, please bring your favorite pencils.
If unwanted hair is normally removed in the area to be treated, i.e.; tweezing or waxing, the hair removal should be done at least 24 hours prior to your procedure. Electrolysis should not be done within five days of the procedure. Do not resume any method of hair removal for a week after the procedure.
If eyelashes or eyebrows are normally dyed, do not have that procedure done within 48 hours of this procedure. Wait one week after the eyebrow or eyeliner procedure before dying lashes or brows.
If you wear contact lenses and are having the eyeliner done, do not wear your lenses to your appointment and do not replace them until the day after the procedure.
If you are having the eyeliner procedure done, as a safety precaution, in case of watering or swelling, we recommend that you have someone available, or accompany you, who could drive you home if you so decide, so if it is necessary.
If you are having lip liner done and you have had previous problems with cold sores, fever blisters, or mouth ulcers, the procedure is likely to reactivate the problem. Your Intradermal Technician can make recommendations to help prevent or minimize the outbreak.
We recommend allergy testing of the red pigment (lip liner or skin tone pigments) one week before the planned procedure.
Do not use aspirin or ibuprofen for 7 days prior to the procedure.

We look forward to working with you. If you have any questions, please call or make notes so we can discuss them with you when you arrive for your appointment.

Medical History Form

Person to contact in case of an emergency:

PRE-TREATMENT ADVICE AND PROCEDURES