Client Information Sheet

CLIENT INFORMATION SHEET

NAME DATE______ ___

ADDRESS _____________ CITY_________________ZIP_________

CELL PHONE ALT PHONE

EMAIL________________________________________________DOB______________

PROCEDURES DESIRED:

Eyeliner Eyebrows Lipliner Full Lip Color Areola Pigmentation

Lash Enhancement Skin Repigmentation Scalp Scar Camouflage Other _______________________ ____

PRACTITIONER NOTES:

Photo Taken: Before After

Needle Size:______________ Pigment Color:

Notes:___________________________________________________________________

Have you ever had a cold sore? Yes No If yes, you must contact your physician for a prescription of ZOVIRAX capsules, an antibiotic which prevents cold sores.

How did you hear about us?

Are you currently under the care of a physician? Yes No

If yes, Why?

Physician’s name:

Do you take antibiotics when going to the dentist? Yes No

If Yes, Why? _______________

Do you have: Allergies Moles or freckles at site of tattoo Hepatitis Bleeding Disorder Heart Problems Hemophilia Diabetes Skin Problems Scarring (Keloids) Eye Problems Epilepsy Other: Please explain:

Any risk factors for Bloodborne pathogen exposure? Yes No

Are you presently taking any medication which thins the blood? Yes No

Are you taking other medications? Yes No If yes, explain:

Are you pregnant or nursing? Yes No

Do you wear contact lenses? Yes No

I understand that if I cancel my appointment within one week, I agree to a charge of $50.00

*Signed: _______ (Client) Date: ______