consultform

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

PERMANENT COSMETICS
Consultation Form

Referred By:

(Business, Organization or Individual)

Name:

Home Phone

- Area Code Phone Number

Address:

Mobil Phone

- Area Code Phone Number

City, State, Zip:

E-mail:

Are you currently under the care of a Physician ?

Yes No

List all medications you are currently taking:

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

I'm Interested In:

	Choose
Lips
Eyebrows
Lash / Liner
Aerola
Scar Camoflauge

What applies to me:

	Select all that apply:
Allergic to Latex
Hormone Replacement
Tanning / Tanning Beds
Using Exfoliating Products
Contact Lenses
Pacemaker

What applies to me:

	Select all that apply:
Taking Aspirin
Blood Thinners
Bruise Easily
High Blood Pressure
Herpes / Cold Sores

Did you select Herpes / Cold Sores ?*

Yes No

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.

Best time to call:

am pm

Questions / Comments

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