Permanent Makeup Medical History Permanent Makeup Client Form Name* First Last DOB:* MM DD YYYY Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Pre-Care Instructions: Check each box below* Refrain from alcohol, any and all blood thinners, such as Coumadin, Aspirin, Ibuprophin and all other types of pain reflief medications containing these with the exception of Tylenol products, seven days prior and two days after all procedures. Be sure to consult your physician before discontinuing Dr. prescribed medication. Judgment altering drugs should be avoided 24 hours prior to all procedures as well. Do not wear contact lenses during or immediately following the eyeliner procedure. You may resume wearing them after your eyes return to their "pre-procedure" condition." Do remember to bring your glasses and sun glasses with you. There should be no eyelash or eyebrow tinting or curling of the lashes 48 hours prior to your procedure and no sooner than two weeks after. Botox and fillers should be done 2-3 weeks prior or after permanent makeup procedure. Are you under a doctor's care?* Yes No If yes, please explain:Do you have any tattoos?* Yes No Any prior permanent makeup?* Yes No Do you bruise easily?* Yes No Eyes: Select all that apply: Dry Eyes Contact Lenses Glasses Corneal Abrasion Eye drops or Ocular Medications Eyelid Surgery Glaucoma Cataracts Visual Disturbances Light Sensitive Eye Infections Blepharitis (eyelids) Skin: Select all that apply: Skin Cancer Moles Rosacea Scars Acne Vitiligo Psoriasis Using Retin-A Chemical Peels Plastic Surgery Laser Treatments Hyperpigmentation (dark spots) Hypopigmentation (white spots) Allergies: Select all that apply: None I know of Local Anesthetics Nickle/Metals Hair Coloring Makeup/ Mascara, ect. Medications: Select all that apply: None Vitamins/Herbs Aspirin Ibuprofen (Advil or Aleve) Hormones Medications High Blood Pressure Heart Pills Water Pills Pain Pills Anti-Depressants Blood Thinners Thyroid Medication Insulin (Diabetes) Fever Blister Medication General Health: Select all that apply: Alopecia (hair loss) Anemia Arthritis Cancer Hepatitis HIV Seizures Dizziness Depression Headaches Sugar Diabetes High Blood Pressure Asthma Eye Problems Liver Kidney Pregnant Nursing Skin Type* Fitzpatric l : White, Very Fair, Red or Blonde Hair, Blue Eyes, Freckles. Characteristics: Always Burnes, Never Tans Fitzpatric ll : Skin Color - White; Fair; Red or Blonde Hair, Blue, Hazel, or Green Eyes. Characteristics: Usually Burns, Tans with Difficulty. Fitzpatrick lll : Skin Color - Cream White, Fair with any Hair or Eye Color, Very Common. Characteristics : Sometimes Mild Burn, Tans Gradually. Fitzpatrick lV : Skin Color - Brown, Typically Mediterranean Caucasian Skin, Characteristics: Rarely Burns, Tans with Ease. Fitzpatrics V : Skin Color - Brown, Mid-Eastern Skin Types. Characteristics : Very Rarely Burns, Tans Very Easily. Check the box that best describes your skin type.Please provide additional information that I should be aware of:Date SignaturePhoneThis field is for validation purposes and should be left unchanged.