• Michelle Jennings, RN., ICS., FAAM
    www.MichelleJenningsRN.com
    (727) 410.0452

    PERMANENT COSMETICS
    Consultation Form

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  • Services Requested / Conditions... Select all that apply:                                 

  •   Choose
    Lips
    Eyebrows
    Lash / Liner
    Aerola
    Scar Camoflauge
  •   Select all that apply:
    Allergic to Latex
    Hormone Replacement
    Tanning / Tanning Beds
    Using Exfoliating Products
    Contact Lenses
    Pacemaker
  •   Select all that apply:
    Taking Aspirin
    Blood Thinners
    Bruise Easily
    High Blood Pressure
    Herpes / Cold Sores
  • If I have checked Herpes/Cold Sores I am required to consult with my Physician about anti-viral options. I understand that it is my responsibility.  An outbreak during healing can disrupt the final result of my procedure.

  • When you've completed the form you can SUBMIT ONLINE by clicking "SUBMIT" below.
    Your information will go directly to Michelle Jennings, RN.

    You can also complete the form online, then print.

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