Client Pre-screening form

CLIENT INFORMATION REQUIRED FOR PERMANENT COSMETICS/ VITILIGO/ AREOLAR TREATMENTS

Fields or sections marked by an asterix (*) are required

I have been informed that this is a two-part procedure and for the best result a touch-up procedure is required 4 - 6 weeks after the original treatment as colour of the pigment used may fade. Second session (touch-up): Charged at 75% of original treatment price as per the current in-salon price list. NOTE: Appointments not cancelled 24 hours in advanced are charged at 25% of the treatment cost.

List any drug, food, make-up or skin allergy that you have. This includes soaps, cleansing creams, earrings (other than gold) Novocain (local anaesthetic) or any derivatives of caine, latex, powders, menthol, petrolium, sulfa and zinc: (if you have no allergies type 'None' into the text box)

Do you have or have you had any of the following conditions?

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