Client History Form

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Address:
3209 Paces Ferry Place
Atlanta, Georgia 30305

Office: (404) 229-7372
Email: makeupatlanta@yahoo.com

Websites:
permanentmakeupofatlanta.com
hairsimulation.com

CBS NEWS 46 Permanent Makeup of Altanta Eyebrows

Client History Form

Thank you for expressing interest in Permanent Makeup of Atlanta. To better assist you, please complete the Client History Form.

CONTACT INFORMATION

Name: *

Phone Number: *

Email Address: *

Do you wear contact lenses ? ( If so, bring glasses to procedure) *

Are you on any medications? If so, e-mail me a list of medication. *

Are you using blood thinners, aspirin, steroids, acutane...? *

Have you had a cold sore in the past? (If so we suggest using Valtrex 1 week before and one week after procedure) *

Have you had any eye surgery? *

Are you allergic to any food or medication? This includes antibiotics ointments and Latex . If so, e-mail me the details *

Do you have any blood diseases? *

Do you use Retin A? If so discontinue two weeks before until procedure heals. *

What procedures are you interested in? *

Do you want a patch Test (this is required for scar/ breast camouflage only)? *

May I use your Photo? *

I understand that I have read the nature of my Permanent Cosmetics Treatment, and the risks. I consent to Cheryl Rosenblum/Nishawne Hinds performing the procedure. Being of sound mind and body, I hereby release Cheryl Rosenblum/Nishawne Hinds and accept r *

I have read and understand the aftercare requirements. *

I am over the age of 18. *

If I have any type of allergic reaction I will contact my doctor ASAP, and notify Cheryl Steinberg. *

Are you pregnant? *

What Type of Payment form will you be using? Note: We do not accept credit/debit cards *

Do you have "Mitral Valve Prolapse." If so you will need to inform your Doctor and get proper medication. *

Do you plan on having laser done on your face. If so have your doctor cover the tattooed area. *

How did you hear about me? *

I understand not to get collagen after full lip procedure. *

I understand not to put anything on tattooed area for at least 10 days. *

I understand to only use the shea butter given and nothing else, and that if I use anything else I may have complications (i.e.: cold sores, blisters, color loss, blotchy color, swollen eyes, allergic reaction...) *

I will e-mail phone number and person to contact in case of an emergency. *

Yes. I agree and will enter the information below.
Enter Contact Name and Phone Number:

Have you had other tattoo? *

Do you Keloid? *

I understand that I need to print out this form and bring the history form to my first appointment. *

I understand that there is a risk of an eye infection if the eye area is not kept clean (keep shea butter out of the eye area use only in the lash line). There also is a slight risk of a abrasion on the Cornea in eyeliner procedures. Abrasions can be caus *

I understand that several touchups may be required and that all skin takes the ink and color different. Color needs to be checked at least once a year. I also understand there are no refunds on permanent makeup procedures. *

For hair simulation clients. I understand that desired results can take a few sessions. If I shade my hair a dark color, I need to keep that dark color or the shading may not look natural. i.e. Hair shading may fade, and touchups may be required. I have r *

By signing I am confirming that I have correctly competed the client history form and have disclosed all information required. *

I Agree. I will enter my name below.
Client's Name: