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New Client Intake

Personal Information

Today's Date * required

First Name

Last Name

Street Address

City

Region/State/Province

Postal / Zip code

Email Address

Phone

Birthday * required

Age

Emergency Contact

Phone

Have you ever had permanent makeup procedure before? *

Yes

No

Treatment Interested * Required

Powder/Ombre Brows

Nano Brows

Eyelash Enhancement

Classic/Wedge Eyeliner

Winged Eyeliner

Ombre Eyeliner

Lip Blush

Beauty Mark

PMU/Tattoo Removal

Tiny Tattoo

Inkless Stretchmark Revision

SMP (Scalp Micropigementation)

Laser PMU/Tattoo Removal

What would you like to improve/change about the area?

How did you find us?

For Brow Client

Do you have mole, scar, or other anomalies in or around the brow area? *

Yes

No

Not Applicable

Do you have or have had a piercing in the brow area? *

Yes

No

Not Applicable

Have you had a hair transplant for your eyebrows? *

Yes

No

Not Applicable

For Eye Client

Do you wear contact lenses? *

Yes

No

Not Applicable

Do you use Latisse or eyelashes growth serums? *

Yes

No

Not Applicable

Do you currently have eyelash extensions? *

Yes

No

Not Applicable

For Lip Client

Have you ever had a Herpes Simplex Type I infection? Also called cold sores/fever blisters *

Yes

No

Not Applicable

Next Section

Do you have, or do you think it is possible you may have a Blood Borne Communicable Disease? *

Yes

No

If so, please all applicable

Hepatitis C

Hepatitis B

HIV/AIDS

Do you currently have any other form of communicable disease, or infection? e.g. respiratory infection, gastrointestinal infection, skin infection, ear or eye infection, bacterial, fungal or viral infection etc. *

Yes

No

If yes, please explain

Do you have Diabetes, currently on any form of immuno-suppressant therapy, or have any other condition that may cause delayed healing? *

Yes

No

If yes, please explain

Do you have any Hypersensitivity, Auto-Immune Disorder, or Allergic Conditions? *

Yes

No

If yes, please explain

Have you ever taken a medication containing Bisphosphonate/Diphosphonate? e.g. fosamax, alendronate *

Yes

No

Do you have any form of bleeding disorder, or are you taking any anticoagulants (blood thinners)? *

Yes

No

If yes, please explain

Have you had any form of Cosmetic or Surgical Procedure, Radiotherapy, or Chemotherapy at any time during the past 6 months? *

Yes

No

If yes, please explain

Do you suffer from any form of hyper-pigmentation skin conditions? *

Yes

No

If yes, please explain

Do you suffer with fainting, blackouts, or seizures? *

Yes

No

If yes, please explain

Do you have a cardiac pacemaker, Implanted Cardioverter Defibrillator (ICD), have a serious heart condition, or abnormal blood pressure? *

Yes

No

If yes, please explain

Do you have any form of acute or chronic eye condition? *

Yes

No

If yes, please explain

Are you prone to developing Telangiectasia? Spider vein *

Yes

No

Do you smoke? *

Yes

No

Do you have any allergies or sensitivity to latex/rubber? *

Yes

No

Do you regularly sun bathe or use tanning salon? *

Yes

No

Do you receive skincare treatments such as botox, filler, peels, etc...? *

Yes

No

Are you currently taking any medications, herbs, vitamins? *

Yes

No

If yes, please indicate the treatment, when it was last done and when is your next appointment if any.

Please list all medications including prescription, over-the-counter and vitamins

Do you have a known allergy or sensitivity to any topical or local anesthetics including dental anesthetics? *

Yes

No

Do you have a known allergy or sensitivity to any ingredients within tattoo ink or pigments, regular makeup, any preservatives, hair dyes, or other dyes? *

Yes

No

Do you have a known allergy or sensitivity to any ingredients in tattoo aftercare creams, antiseptics, lanolin, or petrolatum (petroleum jelly)? *

Yes

No

A patch test is offered in case of an allergic reaction to numbing agent and/or pigments. However, it does not ensure a client will not have an allergic reaction. If declined, I (client) release Golden Compass PMU Studio from liability if I (client) develop an allergic reaction to the pigment. If you require a patch test, YOU MUST contact us a week in advance to make an appointment for the patch test.

Do you need a patch test? *

Yes, I do need a patch test

No, I do not need a patch test.

Is there any additional information you would like to tell us?

Please read the following statements carefully. Permanent makeup is a way of cosmetic tattooing, intended to be permanent lasting an average of 12-36 months or longer. On rare occasions, the pigment may migrate under the skin. The procedure of permanent makeup may be uncomfortable. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be performed if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after permanent makeup procedure, you should notify/ discuss with your doctor. Possible scar-ring may occur.

Click here for Aftercare information

By checking this box, I've agreed that I have received Aftercare information and I’m fully aware of the Aftercare procedures. I fully understand the information provided above & confirm that all information provided by me is correct and truthful.

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