Consultation Form

Consultation Form

Name *
E-mail Address *
Street Address *
City, State,Zip *
Home Phone *
Cell Phone *
Services Requested *
Are you under any Physicians Care? *
List all medical conditions and medications you are taking.
Desired Location of Service *
Please check any of the following that apply.	Taking aspirin products Blood Thinners Bruise Easily Contact Lenses Herpes or Cold Sores Hormone Replacement Tanning including Tanning Beds Use of Exfoliating products Pacemaker High Blood Pressure Allergic to Latex
If I have checked Herpes/ Cold Sores I am required to consult my Physician about antiviral options. I understand it is my responsibility. An outbreak during healing can disrupt the final result of my procedure. *	I understand this directive.
What is the best time to reach you?
Best Day And Time For Appointment
Have you ever had a reaction (even slight) to any topical cosmetics or creams? *	yes no
If YES to the above Question. It is recommended that you receive a "patch test" 2 weeks before your procedural date. *
If this appointment is for Corrective Work, Please list where original work was done, the technicians name and if you remember the brand and color that was implanted.