Hair By Denise

Permanent Makeup Consult

First Name
Last name
Best contact number include area code
E-mail address
What procedures are you inerested in?	Lipliner Lip Shade Full Lip Eyebrows Eyeliner Full Lip Beauty Mark Areaola Repigmentation Scar Camofllauge Tattoo or Permanent Makeup Removal Other
List any medications that would interferre with receiving permanent makeup or the healing process	Blood Thinners Asprin Steroids Accutane Retin A Other None
List any illnesses or conditions that would interferre with receiving permanent makeup or the healing process.	Epilepsy Diabetes Hemoplilia Liver Disease Kidney Disease Heart Condition Transplant Recipient Skin Cancer Psoriasis Vitiligo Eczema Dermatitis Keloids Asthma High Blood Pressure Psoriasis Glaucoma Dry Eye Syndrome Blocked Tear Ducts Currently Pregnant Breast Feeding Other None
List any allergies that would interferre with receiving permanent makeup or the healing process.	Seasonal Allergies Latex Topical Anestetics Metals Permanent Makeup Pigments Tattoo Inks Other None
I understand that photgraphs are taken for documentation purposes.	Yes No
I understand that permanent makeup is a permanent change.	Yes No
I understand permanent makeup has color variations & can fade over time, especially with tanning or smoking.	Yes No
I understand permanent makeup carries risks such as infection, scarring, allergic reaction, corneal scratches, granulomas,	Yes No
I understand i cannot wear contacts after permanent makeup to the eye for 1 week.	Yes No
I swear i do not have an impairment that wouls affect my descision to get permanent makeup.	Yes No
I understand that any work needed to be redone due to negligence will be redone at full price.	Yes No
I understand i may not have anyone in the room during my permanent makeup procedure This is to prevent injuries.	Yes No
I understand that i must get a Valtrex prescription for permanent makeup lip procedures if i have ever had a coldsore.	Yes No
I understand that permanent makeup corrections & permanent makeup/tattoo removals may require multiple sessions & is more likely to have higher risks invlved.	Yes No
I consent to Hair By Denise & Affiliates to use my photos for advertsing purposes only.	Yes No
I waive the patch test (2 weeks before procedure at $50)	Yes No
I have consented to the colors	initial after consenting
I have consented to the design	initial after consenting
I have read, understood & agreed to the Hair By Denise Company Policy & Permanent Makeup caresheet.	Yes No
Electronic Signature (Please type your name) for online estimate Sign your name in ink for your personal consultation.

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