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PMA Beauty - Microblading & Lashes
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Customer Questionnaire
Name
*
Phone
*
Pregnancy
*
Yes
No
Breast feeding
*
Yes
No
Active cancer
*
Yes
No
Allergy to pigment (or numbing cream, food, metal etc.)
*
Yes
No
What specific allergy?
Dermographism
*
Yes
No
Tendency for keloid formation
*
Yes
No
Herpes or cold sore
*
Yes
No
HIV
*
Yes
No
Eye problem
*
Yes
No
What specific eye problem?
Skin problem
*
Yes
No
What specific skin problem?
Asthma
*
Yes
No
Hepatitis A, B, C
*
Yes
No
Diabetes
*
Yes
No
Autoimmune Disease
*
Yes
No
Heart Problems
*
Yes
No
Keloids
*
Yes
No
History of Fainting
*
Yes
No
Epilepsy
*
Yes
No
Blood Thinners
*
Yes
No
Are you currently taking any medication?
*
Yes
No
Medication name
Are you currently under the care of a physician?
*
Yes
No
Aspirin, alcohol or drugs acceptance during within 24hr?
*
Yes
No
Do you have any other tattoo?
*
Yes
No
Procedure
*
Eyebrows
Eyeliners
Lips
Hairlines
Scalp
Color removal
I'm over the age of 18, I am not under the influence of drug or alcohol and desire to receive the indicated permanent cosmetic procedure.
*
Yes
No
If I am on any medication for depression or any other mood altering prescription, I'll advise my technician.
*
Yes
No
Signature
*
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