Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about us? Are you allergic to topical anesthetics? * Yes No If yes, please specify: Do you have any allergies we should be aware of? * Yes No If yes, please specify: Do you have any tattoos? * Yes No Are you diabetic? * Yes No Does your skin swell easily? * Yes No Are you currently pregnant or breastfeeding? * (If you are either pregnant or breastfeeding, you cannot get any permanent makeup procedure done) Yes No Do you have any heart conditions? * Yes No Have you ever been tested positive for HIV or Hepatitis? * Yes No Do you have any other medical conditions we should be aware of? * Yes No If yes, please specify: Are you currently taking any medications, including immunosuppressant such as an anti-inflammatory or steroid? * Yes No Are you able to take over-the-counter antihistamine? * Yes No Thank you!
