Kathleen Cronin, RN, CPCP Restorative MicroPigmentation Specialist COLOUR COSMETIC STUDIO
Kathleen Cronin, RN, CPCP Restorative MicroPigmentation Specialist COLOUR COSMETIC STUDIO 

Client information sheet

Colour Cosmetic Studio, inc.
1525 Western Ave., Suite 2
Abany, NY  12203
518-776-0067

                                                                                                                            Date ______/_____/_______

 

Name ____________________________________________________________________

 

Date of Birth ______/_____/_____

 

Email: ___________________________________________________

 

Address ___________________________________________________ City:________________________________State ___________ Zip ______________

 

Home Phone (_____)______________________

Cell (____)______________________________

 If we call you at home, do you want confidentiality?         No      Yes

May we call you at work?      No ____  Yes   ____ 

       If Yes, my work number is (_____)____________________

Emergency Contact: Name ________________________________________________

Phone ( ____)_______________ Relationship_______________________

 

Driver's license #______________________________________________

 

Copy of license___________or Legal Photo ID___________________

_(required by NYS Health Dept.)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~`

 

Procedure(s) desired:  Eyebrows  ___  Eyeliner____   Lips____  Camouflage____Areola ______ Skin pigment/Scar Correction____

 

Ethnic Background, please include all nationalities (This helps determine color and healing:_______________________________________________  (Irish, Italian, Greek, African, Indian, etc. (this information helps to determine skin types and healing tendencies)

 

How did you find our services?  __________________________________

Who may we thank for referring you?  _____________________________

 

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MEDICAL QUESTIONAIRE

IMPORTANT:  IF YOU ANSWER YES OR CHECK ANY OF THE FOLLOWING QUESTIONS,  

YOU MUST ARRANGE A TELEPHONE CONSULT

AT LEAST 1 WEEK PRIOR TO YOUR PROCEDURE APPOINTMENT.

 CALL 518-776-0067 TO ARRANGE THIS CALL.  

CALL WILL BE 15 MINUTES.


List all medications you are presently taking

(You do not need a consult if you are taking Birth Control Pills or Replacement Hormones)

 

Name of drug                                        Mg. or mcg.         How many ea. day       

  1. ______________________________    ________           __________          
  2. ______________________________    ________           __________                  
  3. ______________________________    ________            __________                  
  4. ______________________________    ________            __________
  5. ______________________________    _________          __________ 

 List all medications you took in the last six months that you are no longer taking:

 

Name of drug                                         

  1. ______________________________                
  2. ______________________________  
  3. ______________________________
  4. ______________________________                     

 

Do you have? (check all that apply)

  • Fever Blisters/Cold Sores ____ (This is important if you are having lips done)
  • Glaucoma or other eye disease/disorder _____          
  • Grave’s Disease_____                                  
  • Heart Disease_____                   
  • Mitral Valve Prolapse_____               
  • Valve Implants_____                             
  • Pacemaker    _____                   
  • Stents_____    
  • Diabetes requiring insulin      _____
  • Problems with healing _____                            
  • Keloids _____
  • Seizures _____               
  • Dermatological Disorder _____
  •        If so, what? ______________________
  •        Active or in Flare-ups? _____________
  • Hemophilia or Clotting Disorder ______          
  • Autoimmune Disorder ______                            
  • Pre-existing nerve damage ______           
  • Trichotillomania (pulling of hair, brows, lashes)   ______
  • Alopecia Totalis or Areata______
  • Tattoos _____ Where are they? ________________________________________ 
  • Colors you are sun sensitive to: -__________________________

Allergies_None  Known  x_____
List: 

  1. _______________
  2. ____________
  3. _______________
  4. ____________ 

 

Are you? (check all that apply)

  • Pregnant or breast feeding? X          ( you may not have procedure if you ans yes to either of these)
  • Planning cosmetic surgery____If so, what & when? ________________________________
  • Currently under the care of a physician for any medical issue:_____

Describe: __________________________________________________ ________________________________________________________

 

Do you use? (check all that apply)

  • Accutane (currently or within the past year) ______        
  • Antibiotics prior to dental procedures______
  • Steroids______
  • Chemotherapy or Prophylactic dose of Chemotherapy_____
  • Blood Thinners____
  • Daily Aspirin or Ibuprophen_________
  • Retin-A, Glycolic Acid, Vitamin C or other Exfoliants____
  • Tanning Beds_____
  • Eyebrow Tinting_____
  • Eyelash Tinting_____
  • Latisse_______ Last used: ________ (For eyeliner, you must be off growth serums for 6 weeks)
  • Botox  _____    When___________(Botox or generic Rx. must at least 3 weeks from last injections)
  • (Chemical Peels______ When__________________________________________________________
  • Lip injected fillers _______  ( Consult is requried to book lip liner or fill if you answered yes )

 

Have ever you had? (check all that apply)

  • Fever Blisters/Cold Sores (Ever, even one time)    _____
  • Infections (Are you prone to them)_______
  • Vision Correction Procedure (Lasik, RK) within the past 3 months_______
  • Heart Attack____  - When? __________
  • Joint Replacement, Organ Transplant _______
  • Eye Trauma or surgery _______
  • Seizures_______
  • Fainting Spells_____
  • Hepatitis___________ What Type:_________
  • Hepatitis Test _______When? __________
  • Fat Transfer Injections___________     If yes, where? __________
  • Gore-Tex Implants -  If yes, where? __________
  • Aesthetic or Cosmetic Procedures _________    If yes, where? __________
  • Laser Treatments______    What type & why? ___________

IMPORTANT

  •  If you are taking any blood thinners, Steroids or Disease Mondifiers, Chemo, etc., you must call for a consult.
  • You must refrain from Alcohol ,Fish oils, Ibuprophen and Aspirin products 24 hours prior to you appointment.  
  • Caffeine must be avoided 6 hours prior to procedure.

 Client Name (print) ______________________________________

Client sign: ______________________________________Date______/_____/_____

Technician: __________________________Date:       /        /

1525 Western Ave. Suite 2
Albany, New York 12203
Phone: +1 518 491-1556+1 518 491-1556
Fax: null
E-mail Address:
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