COLOUR COSMETIC STUDIO, inc.
COLOUR COSMETIC STUDIO, inc.

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?  _____________________________

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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______/_____/_____

Tattoo Artist: ______________________________Date:       /        /

COLOUR COSMETIC STUDIO, inc.
1525 Western Ave. Suite 2
Albany, New York 12203
Phone: +1518-776-0067 +1518-776-0067
Fax: null
E-mail Address:
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