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BROWS BY JENNY

PMU & ACADEMY

PERMANENT MAKEUP CLIENT INFORMATION FORM

For a more effective, personalized treatment, please be as accurate as possible when filling out the following information

First name*

Last name*

Birthday*

Month

Day

Year

Email*

Phone*

Address*

How did you hear about Brows by Jenny?*

Instagram

TikTok

Google Search

Friend or Family Referral

Have you ever had a cosmetic tattoo or permanent makeup procedure before?*

Yes

If yes, what was it for and when?

Do you have moles/raised areas in or around the treatment area?*

Yes

Do you have or have you had a piercing in treatment area?*

Yes

What would you like to improve/change about the area? Consider shape, color, density, thickness...

Are you, or is it possible you may be pregnant?*

Yes

Are you currently breast feeding?*

Yes

MEDICAL QUESTIONNAIRE

Are you prone to keloid scarring, hypertrophic scarring, or any other form of excessive scarring condition?*

Yes

Have you taken a medication containing Isotretinoin (e.g. Roaccutane) during the previous 12 months?*

Yes

Do you have, or do you think it is possible you may have a Blood Borne Communicable Disease? e.g. Hepatitis C Virus (HBC), Hepatitis B Virus (HBC), Human Immunodeficiency Virus (HIV)*

Yes

Do you currently have any other form of communicable disease, or infection? e.g. respiratory infection, gastrointestinal infection, skin infection, ear or eye infection, bacterial, fungal or viral infection etc.*

Yes

Do you have Diabetes, currently on any form of immuno suppressant therapy, or have any other condition that may cause delayed healing?*

Yes

Have you ever had a Herpes Simplex Type I infection (also called cold sores/fever blisters)?*

Yes

Do you have any Hypersensitivity, Auto-Immune Disorder, or Allergic Conditions?*

Yes

Do you have a known allergy or sensitivity to any topical or local anesthetics including dental anesthetics?*

Yes

Do you have any form of bleeding disorder, or are you taking any anticoagulants (blood thinners)?*

Yes

Have you had any form of Cosmetic or Surgical Procedure, Radiotherapy, or Chemotherapy at any time during the past 6 months?*

Yes

Do you suffer from any form of hyper-pigmentation skin conditions?*

Yes

Do you suffer with fainting, blackouts, or seizures?*

Yes

Do you have a cardiac pacemaker, Implanted Cardioverter Defibrillator (ICD), have a serious heart condition, or abnormal blood pressure?*

Yes

Do you have any form of acute or chronic eye condition?*

Yes

SPECIAL PRECAUTION

Are you currently taking any medications, herbs, vitamins?*

Yes

If yes, please specify

Do you have an allergy or sensitivity to latex/rubber?*

Yes

Do you smoke?*

Yes

Do you have a known allergy or sensitivity to any ingredients within tattoo pigments or needles, regular makeup, any preservatives, hair dyes, or other dyes?*

Yes

Have you used any eyelash or eyebrow growth serums / creams or any eye drops that may contain prostaglandin analogues in the past 4 weeks?*

Yes

Do you wear contacts?*

Yes

If yes, please wear glasses instead on the day of your appointment.

Is there any additional information about you that we should know before starting your treatment?

Driver License/Government ID*

Picture of Current Eyebrows (No makeup/filter on)*

Permanent Makeup is a cosmetic tattoo designed to last approximately 12–36 months. The procedure may cause some discomfort, and mild redness, swelling, or minor bleeding can occur afterward. In rare cases, pigment migration, infection, allergic reactions to pigment or anesthetic, or scarring may occur.

Following proper aftercare instructions is essential to prevent complications. Permanent makeup cannot be performed on clients who are pregnant, nursing, or under 18 years old.

If you plan to have an MRI within 3 months after your procedure, please inform your doctor that you have had permanent makeup.

By proceeding with your appointment, you acknowledge that you understand the risks associated with this procedure.

I fully understand and acknowledge the information provided above & confirm that all information provided by me is correct and truthful.

Signature*

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