Copperleaf Permanent Makeup Questionnaire

Today’s Date: ______Drivers License Number______

Name: ______DOB: ______Age: ____ Sex: ____

Address: ______ST: _____ Zip: ______

Phone: ______Cell: ______Email: ______

Emergency Contact: ______Phone: ______

Skin Type: Fair ______Medium ______Tan ______Deep: ______

*Whom may we thank for referring you? ______

Do you have any questions regarding this procedure? ______

______

Please list any medications you are taking and for what reason?

______

Allergies: (medications, creams, adhesive tape, ointments, milk, apples, citrus, grapes, aloe vera, etc.) ______

What reactions have you experience from an allergy? ______

______

Past Types of anesthesia (Inpatient or Outpatient): ______

______

Have you had any type of surgery or invasive procedure in the past 30 days?______

______

Have you ever experienced any reactions with anesthesia? ______

If yes, please explain: ______

Have you ever had: Yes No: Yes No:

High blood pressure ______Liver Disease ______

Heart problems or stroke ______Cancer ______

Angina ______Varicose Veins ______

Shortness of breath ______Anemia ______

Pulmonary Embolism ______Astnma/ Bronchitis ______

Migraine Headaches ______Fever Blisters ______

Hemophilia ______Blood Transfusion ______

Stomach Problems ______Yellow Jaundice ______

Arthritis ______Hepatitis ______

Bell’s Palsy ______Facial Nerve Damage ______

Epilepsy ______Glaucoma ______

HIV ______Glasses/ Contacts ______

Diabetes ______Mitral Valve Prolapse ______

Depression ______Mental Conditions ______

Have you ever received radiation treatment: ______Please Explain ______

Do you smoke? ____ Do you drink ? ____ Are you pregnant? ______

Are you currently under the care of a physician? ______

Physician’s name ______Phone # ______

Skin Care

Are you presently, or have you ever taken Accutane or Retin-A? _____

How long ago? ______

Do you tan? ______Do you have a sunburn or windburn? ______

Do you get facial waxing/ electrolysis/ or use depilatories? ______

Have you had collagen injections lately? ______Date ______

What skin care products do you use? ______

Have you ever had a peel before? ______What kind? ______

Describe your reaction: ______

This facility has a no refund policy. 30% of payment is required on missed appointments without 24 hour notice of cancellation. All appointments require a credit card number to book permanent makeup.

Signature: ______Date: ______

Permanent Makeup Authorization Form

PLEASE READ THE FOLLOWING NOTICE:

You are hereby notified of the possible risks and dangers associated with the application of micro pigmentation. These risk and dangers include, but are not limited to, at least the following:

1. The possibility of discomfort or pain:

2. The permanence of the markings:

3. The risk of infection: and

4. The possibility of allergic reaction to the pigments or other materials used.

NO PERSON MAY BE MICROPIGMENTED WHO APPEARS TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS.

NAME: ______DATE: ______

ADDRESS: ______PHONE: ______

CITY: ______STATE: ______ZIP: ______

I have received a copy of applicable written care instructions and I have read and understand such written care instructions.

Guest Signature: ______Date: ______

To be completed by the artist:

Artist Name: ______

Client Age: _____ Client DOB: ______

Type of valid identification provided: ______

Location of permanent cosmetics: brow lip full lip liner ______

Colors used: ______Catalog #: ______

Colors used: ______Catalog # ______

Pigment may not be implanted on a person younger than 18 years of age meeting the requirements of 25 Texas Administrative Code, 229.406c, whose parent or guardian determines