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New Client Information Form

Please fill out the following to the best of your knowledge:

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information and new by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Do you have or have previously had any of the following:
Accutane or acne treatment*
No
Yes
Yes, more than one year ago (Accutane)
Chemotherapy/Radiation*
No
Yes
Tan by Booth or Salon or Outside*
No
Yes, less than a week ago
Yes 1-3 months ago
Yes: On Occasion (vacation, sporting events)
Tumors/Growths/Cysts*
No
Yes
Keloids*
No
Yes
Difficulty numbing with dental work*
No
Yes
Hepatitis A B C D*
No
Yes
Take Medication before dental work*
No
Yes
Forehead/Brow Lift*
No
Yes
Pregnant/Breastfeeding Now*
No
Yes

Date of Last Menses
Easy Bleeding*
No
Yes
Facelift*
No
Yes
History of MRSA*
No
Yes
History of Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Diabetes*
No
Yes
Autoimmune disorder*
No
Yes
Oily skin*
No
Yes
Brow/ Lash Tinting*
No
Yes: less than one week ago
Yes: more than one week ago
AIDS/HIV*
No
Yes
Chemical Peel*
No
Yes
Last Chemical Peel Done:*
Botox*
No
Yes
~Botox was done*
Epilepsy*
No
Yes
Taking Blood Thinners Such As:*
Has had eyelash extensions before:*
No
Yes

Any Issues?
Has been waxed before?*
No
Yes

Any issues?
Has had permanent makeup done previously?*
No
Yes

If yes, Describe:

Please List any and all allergies:
How would you describe your skin if exposed to 15 minutes of sun without any sun protection?
Choose the best answer:*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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