Sample Client Intake Form

Welcome to ...............................!

This form covers essential information about your health, skin, and preferences, and it includes a consent and agreement section. Below are some question that will make our time together as effective as possible.

First Name
Last Name
Date of Birth :
Choose which procedure you want to get done today
    Beauty Mark
    Scalp Micropigmentation
    Scar Camouflage
    Areola Nipple Pigmentation
Please list any medication you currently take
What are your biggest concerns about your eyebrows?
Are you pregnant or breastfeeding?
Are you a diabetic or bleed excessively? If so, this can affect the way you heal.
May we use your photos to help others get a visual of what to expect?
Who may we thank for referring you?
Read and Check Mark the Following Statements.
Permanent Makeup Consent and Release Agreement

This disclosure is simply an effort to make you better informed so you may give or withhold your consent to the procedure. If you have a question, please don't hesitate to ask. Please type your Full name, state you agreed, and give consent.

Cancellation, No-Show, and Tardiness Policy

All appointments are reserved with a .........  non refundable deposit. We require a ..... hour cancellation/reschedule notice for all appointments, so that we may accommodate the needs of other clients.

Those who do not show for their scheduled appointment or do not allow for the requested amount of time to cancel/reschedule the appointment will be charged 100% of the treatment price.

If you are late for your appointment, you risk having your appointment time reduced. If your time is reduced, you still owe for the entire appointment as booked. For those too late for us to perform any services will still be charged for the full amount of the scheduled service(s). Fees are subject to change.

Please type in Full Name, and state you agree to conditions.


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