Client's information

Full Name

First name

Last name

Date of Birth

Month

Day

Year

Phone Number

Address

The procedure chosen by the client

PLEASE READ CAREFULLY AND SELECT REQUIRED PROCEDURE

The Client hereby confirms that he/she wants to have:

the long-term (permanent) makeup procedure

made to him/her: the injection of a special colour (pigment) in the skin in the facial area to intensify the shape of eyebrows in accordance with the procedure adopted by the authorized institution (a hygienic standard or etc.) in the country in which the procedure is performed.

To perform the procedure chosen by the Client safely, the Client hereby is submitting information by checking boxes by “x” respectively. If the Client deems it necessary, he/she indicates additional information on supplementary pages, which is that the Client indicates diseases he/she has or/and medicines he/she administers.

HEALTH & SAFETY QUESTIONNAIRE

Hemophilia

Yes

No

Diabetes mellitus

Yes

No

Hepatitis A, B, C, D, E, F

Yes

No

HIV

Yes

No

Skin diseases

Yes

No

Eczema

Yes

No

Allergies

Yes

No

Autoimmune diseases

Yes

No

Are you prone to herpes

Yes

No

Infectious diseases

Yes

No

High fever

Yes

No

Epilepsy

Yes

No

Cardiovascular problems

Yes

No

Are you taking a medication for blood thinning (anticoagulants)?

Yes

No

Are you pregnant?

Yes

No

Are you taking any medications on a daily basis?

Yes

No

Do you have a pacemaker

Yes

No

Do you have problems with healing of wounds?

Yes

No

Have you consumed drugs or alcohol in the last 24 hours

Yes

No

Did you undergo a surgery in the last 14 days, where you were exposed to radiation or did you have any other medical interventions?

Yes

No

Did you have any surgery or inpatient medical treatment in the last 14 days?

Yes

No

Menstruation on the date of performance of a procedure (increased sensitivity to pain and a local swelling is possible after a procedure if the procedure is made immediately prior or during the first days of menstruation)?

Yes

No

Are you sensitive to pain, blood or fear of needles?

Yes

No

Other problems: recently made chemical peelings, other procedures, facial surgeries, skin sensitivity to mechanical actions, removals, and etc.?

Yes

No

Pre-Treatment

Client's information

The procedure chosen by the client