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info@hushnwa.com

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Full Name

Date

Age

Date of Birth

Choose

Male

Female

Non-Binary

Street Address

City

State

Zip code

Phone

Email

How did you hear about us?

MEDICAL HISTORY

Please mark any of the following conditions you may currently have

Choose

Alopecia

Anemia

Cancer

Circulatory Problems

Cold sores or fever blisters

Diabetes

Eczema

Epilepsy

Choose

Fainting spells or dizziness

Hair Loss

Healing problems Hemophilia

Hepatitis

High Blood Pressure

HIV

Hypertrophic or keloid scars

Joint Replacements

Choose

Liver Disease

Low Blood pressure

Prolonged bleeding

Sensitivity to cosmetics

Thyroid disturbances

Trichotillomania

Tumors growths cysts Others

Any known allergies?

NO

YES

If yes, please explain

List any medications you take regularly including vitamins, herbal supplements, aspirin:

Any recent surgery, including plastic surgery?

Do you smoke or consume alcohol?

NO

YES

Are you pregnant or trying to become pregnant?

NO

YES

Have you ever had a cosmetic tattoo or permanent makeup procedure before?

NO

YES

If yes, when was your last procedure?

Do you have moles/raised areas in or around the treatment area?

NO

YES

Do you have or have you had a piercing in treatment area?

NO

YES

Are you currently wearing lash extensions of any kind?

NO

YES

Have you experienced Botox, Restylane or Collagen injections?

NO

YES

If yes, please specify

Do you scar easily?

NO

YES

Do you bruise/bleed easily?

NO

YES

Have you ever had an allergic reaction to any of the following:

Choose

Aspirin

Crayons

Food

Fragrance

Glycerin

Hair Dyes

Lanolin

Choose

Latex

Lidocaine

Medication

Metal

Paints

Vaseline

Other

What are your expectations and goals for the treatment? What would you like to improve/change about the area? Consider shape, color, density, thickness

Any questions or concerns about the procedure?

By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any falsification of my medical history

Signature

Thanks for submitting!

CELEBRATE YOUR NATURAL BEAUTY

Empowering individuals to embrace their unique natural beauty through our semi-permanent cosmetic enhancement services, education and innovation as the leading professionals in our industry.

Located inside La Beaute' Lounge

1401 SE Walton Blvd #209

Bentonville, AR 72712

info@hushnwa.com

4792793088

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