Client information sheet
Colour Cosmetic Studio, inc.
372 New Scotland Ave.
Albany, NY. 12208
518-491-1556
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.)
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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
- ______________________________ ________ __________
- ______________________________ ________ __________
- ______________________________ ________ __________
- ______________________________ ________ __________
- ______________________________ _________ __________
List all medications you took in the last six months that you are no longer taking:
Name of drug
- ______________________________
- ______________________________
- ______________________________
- ______________________________
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:
- _______________
- ____________
- _______________
- ____________
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: / /
Osborne Rd. 264
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