Client
History Form

Thank you for your interest in The Hair Simulation Company in Atlanta, Georgia. Please complete the Client History Form below so we can send you our recommendations.

CONTACT INFORMATION

Name: *



Phone Number: *



Email Address: *



Do you wear contact lenses ? ( If so, bring glasses to procedure) *
Please select an optionYesNo


Are you on any medications? If so, e-mail me a list of medication.*
Please select an optionYesNo


Are you using blood thinners, aspirin, steroids, acutane...*
Please select an optionYesNo


Have you had a cold sore in the past? (If so we suggest using Valtrex 1 week before and one week after procedure)*
Please select an optionYesNo


Have you had any eye surgery? *
Please select an optionYesNo


Are you allergic to any food or medication? This includes antibiotics ointments and Latex . If so, e-mail me the details *
Please select an optionYesNo


Do you have any blood diseases? *
Please select an optionYesNo


Do you use Retin A? If so discontinue two weeks before until procedure heals. *
Please select an optionYesNo


What procedures are you interested in? *
Please select an optionBreastEyebrowsEyelinerLipsClassesHair SimulationGeneral Inquiry


Do you want a patch Test (this is required for scar/ breast camouflage only)?*
Not applicableNoYes


May I use your Photo? *
Please select an optionNoYes


I understand that I have read the nature of my Permanent Cosmetics Treatment, and the risks. I consent to Cheryl Rosenblum performing the procedure. Being of sound mind and body, I hereby release Cheryl Rosenblum. *
Please select an optionI agreeI disagree


I have read and understand the aftercare requirements.
Please select an optionYesNo


I am over the age of 18.*
Please select an optionYesNo


If I have any type of allergic reaction I will contact my doctor ASAP, and notify Cheryl Rosenblum. *
Please select an optionI agreeI disagree


Are you pregnant? *
Please select an optionYesNoNot Applicable


What Type of Payment form will you be using? *
Please select an optionCashCheckDebit(Visa ore MC Logo)Credit Card


Do you have *
Please select an optionNoYes


Do you plan on having laser done on your face. If so have your doctor cover the tattooed area. *
Please select an optionNoYes


How did you hear about me? *
Please select an optionTattoo ParlorTelevisionFlyerYouTubeFriend/ReferralInternetReferralOther


I understand not to get collagen after full lip procedure. *
Please select an optionYesNo


I understand not to put anything on tattooed area for at least 10 days.*
Please select an optionYesNo


I understand to only use the shea butter given and nothing else, and that if I use anything else I may have complications (i.e.: cold sores, blisters, color loss, blotchy color, swollen eyes, allergic reaction...) *
Please select an optionYesNo

Who can we contact in case of emergency ?

I understand to enter BOTH Contact Name and Phone NumberEnter Contact Name and Phone Number:

Have you had other tattoo? *
Please select an optionYesNo


Do you Keloid? *
Please select an optionYesNo


I understand that I need to print out this form and bring the history form to my first appointment. *
Please select an optionYes


I understand that there is a risk of an eye infection if the eye area is not kept clean (keep shea butter out of the eye area use only in the lash line). There also is a slight risk of a abrasion on the Cornea in eyeliner procedures. Abrasions can be caus *
Please select an optionYesNo


I understand that several touchups may be required and that all skin takes the ink and color different. Color needs to be checked at least once a year. I also understand there are no refunds on permanent makeup procedures. *
Please select an optionYesNo


For hair simulation clients. I understand that desired results can take a few sessions. If I shade my hair a dark color, I need to keep that dark color or the shading may not look natural. i.e. Hair shading may fade, and touchups may be required. *
Please select an optionYesNoNot Applicable


I agree that I will be free from alcohol and drugs during my procedure

I AGREE

By signing I am confirming that I have correctly competed the client history form and have disclosed all information required. A copy will be emailed after form is submitted. I understand that I must print this form and bring it to my first appointment. *

I Agree. I will enter my name below.Client's Name:

Submit