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Full legal name *

Date of birth *

Phone number *

Email address *

Ethnic background, including all nationalities

Street address

Apartment number

City

State

ZIP code

Home phone

Occupation

If we call you at home, do you want confidentiality? *YesNo

Emergency contact name *

Emergency contact phone *

Emergency contact relationship *

Who may we thank for referring you?

Procedures desiredBrowsLipsFollow-ups

All current medications: drug name, mg or mcg, times each day, and reason prescribed (enter None if none) *

Medications stopped in the last six months: name, dose, times each day, and reason prescribed (enter None if none) *

Do you have? Select all that apply; leave clear if none.Fever blisters / cold sores (ever, even once)Glaucoma or other eye disease/disorderGrave's diseaseHeart diseaseShingles history / recent shingles shotMitral valve prolapseValve implantsPacemakerStentsDiabetes requiring insulinProblems with healingKeloidsSeizuresDermatological disorderHemophilia or clotting disorderAutoimmune disorderPre-existing nerve damageTattoos with colors sensitive to sunTrichotillomaniaAlopecia totalis or areataAllergies

Dermatological disorder: what, and is it active or in flare-ups?

Tattoo colors you are sun sensitive to

List all allergies (enter None if none) *

Do you use? Select all that apply; leave clear if none.Accutane (currently or within the past year)Antibiotics prior to dental proceduresSteroidsRetin-A, glycolic acid, vitamin C or other exfoliantsTanning bedsEyebrow tintingEyelash tintingLatisseBotoxChemical peelsChemotherapy or prophylactic dose of chemotherapyBlood thinners

Botox: when?

Chemical peels: when?

Have you had? Select all that apply; leave clear if none.Fever blisters / cold sores (ever, even once)Eye infections / prone to eye infectionsVision correction procedure (Lasik, RK) within the past three monthsHeart attackJoint replacement or organ transplantEye traumaSeizuresFainting spellsHepatitisHepatitis testFat transfer injectionsGore-Tex implantsAesthetic or cosmetic proceduresLaser treatments

Heart attack: when?

Hepatitis: what type?

Hepatitis test: when?

Fat transfer injections: where?

Gore-Tex implants: where?

Aesthetic or cosmetic procedures: where?

Laser treatments: type and reason

Are you?PregnantPlanning cosmetic surgeryCurrently under the care of a physician

Planned cosmetic surgery: what and when?

Current physician care: describe

Outdoor activitiesTennisSwimmingGolfSkiingGardeningWalkingBoatingOther

Other outdoor activities

Physician's name

Physician's address

Physician's phone

Physician's specialty

Review and sign

Your signature applies to the original form and the completed response record. The studio completes its section separately.

I have reviewed the complete form and my answers. I intend my typed name below to be my electronic signature on this document. I agree to receive this signed record electronically and can download and save a PDF copy. My answers are accurate to the best of my knowledge. For informed consent, I also confirm the risks have been explained and my questions have been answered.

Electronic signature — type your full name *

The signing date and time are recorded automatically. Contact Melissa if you prefer paper forms.

Glow Co. Permanent Makeup · melissa@glowcopmu.com · 7681 Old Shell Rd, Suite C, Studio 3, Mobile, AL 36608

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