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 : Email : Phone : Address: City: State: ZIP Choose which procedure you want to get done today Eyebrows Eyeliner Lips 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. This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. Topical anesthetics are used to numb the area to be tattooed. Pigments and Lidocaine is used, if you are allergic please inform me now. You may request a patch test. There is potential discomfort during the procedure and during healing process. Although rare, there is a risk of Infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care” sheet for instructions on care. Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7 days the color will fade 30-50%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years depending on skin type, lifestyle and personal preference Every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is mandatory to expect a second or third touch-up after the healing is completed. Touch ups are not including in the initial price and charged by sessions. Understand that with oily skin types, strokes can heal less crisp, expanded and/or blurry and may result in a powder-brow effect. Permanent makeup may not take place of your makeup routine. This is a natural way of enhancing your brows. You may still need to fill them in, base on life style & personal preference. Although this procedure is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure. Your artist will draw the shape for you to approve before starting the procedure. It is your duty to schedule a touch up appointment within ... months/weeks of your initial appointment. Anything more than .... months/weeks can be considered a maintenance touch up and will be charged accordingly. Yearly maintenance appointments are recommended and will be at a discount cost from the initial appointment. Anything over two years will be considered a new appointment. I have agreed not to file any claims against ................... All payments are final, no refund. I have read and understand all conditions above. 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. Date