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314.786.5434 | sonaturalinfo@gmail.com

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PATIENT IN-TAKE

This in-take is required yearly for all procedures.

First Name

Last Name

Email

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Birthday

Gender Assigned At Birth * Required

Female

Male

What services are you receiving? * Required

Permanent Make-Up

Facial Services

Medical Injectables

Massage Services

Laser Hair Removal

Morpheus 8

Celluma Light Treatments

IV Infusions

Other

Who is your practioner and how did you select them for your procedure?

Allergies: Check all that apply and describe any reactions you have experienced. * Required

NA

Latex

Benzocaine (topical anesthetic)

Lidocaine (topical anesthetic)

Hydroxyethylcellulose (topical anesthetic)

Epinephrine (topical anesthetic)

Prilocaine (topical anesthetic)

Phenylephrine (topical anesthetic)

Tetracaine (topical anesthetic)

Vaseline

Polysporin

Septisol (medical soap)

Bacitracin Ointment

OTHER

Allergies Explained:

Emergency Contact Name:

Emergency Contact Number

1. Are you pregnant or nursing? * Required

YES

NO

2. Have you had any alcohol in the last 24 hours? * Required

YES

NO

3. Have you ever had cold sores or fever blisters? * Required

YES

NO

4. Have you had a laser or chemical peel within 6 months? * Required

YES

NO

4A. If Yes, Please Explain.

5. Have you ever had any pemanent cosmetics or tattoos? * Required

YES

NO

6. Do you bruise easily for no obvious reason? * Required

YES

NO

7. Do you routinely use Retin-A, glycolic, or other exfoliating products? * Required

YES

NO

8. Do you wear contact lenses? * Required

YES

NO

9. Are you allergic or sensitive to any metals? For instance, metals used in jewelry? * Required

YES

NO

9A. If Yes, Please Explain.

10. Do you have any problems healing? * Required

YES

NO

10A. If Yes, Please Explain.

11. Is your skin oily? * Required

YES

NO

12. Do you use tobacco? * Required

YES

NO

Please check to acknowledge that if you use tobacco you may heal slower and this affects the timing of the scheduling of your check-up or touch-up.

13. Do you have any heart conditions? * Required

YES

NO

13A. If Yes, Please Explain.

14. Are you diabetic? * Required

YES

NO

14A. If Yes, Type 1 or Type 2?

15. Do you have any autoimmune disorders? * Required

YES

NO

15A. If Yes, Please Explain.

16. Are you sensitive or allergic to hand creams or body lotions? * Required

YES

NO

16A. If Yes, Please Explain.

17. Do you have your lips injected with filler materials? * Required

YES

NO

17A. If Yes, Please Explain.

18. Do you have Botox / Neurotoxin injections? * Required

YES

NO

18A. If Yes, Please Explain.

19. Do you menstruate? * Required

YES

NO

19A. If Yes, Please Explain.

20. Do you hyper-pigment (Tendency to develop dark spots on the skin from wounds or sun)? * Required

YES

NO

20A. If Yes, Please Explain.

21. Do you tend to develop keloid or hypertrophy scars? * Required

YES

NO

21A. If Yes, Please Explain.

22. Do you scar easily from minor injuries? * Required

YES

NO

22A. If Yes, Please Explain.

23. Do you have any seizure related conditions? * Required

YES

NO

23A. If Yes, Please Explain.

24. Do you tend to faint or become dizzy? * Required

YES

NO

24A. If Yes, Please Explain.

25. Do you bleed excessively from minor cuts? * Required

YES

NO

25A. If Yes, Please Explain.

26. Do you have prosthetic implants? * Required

YES

NO

26A. If Yes, Please Explain.

27. Do you consume aspirin daily? * Required

YES

NO

27A. If Yes, Please Explain.

28. Are you under treatment for depression? * Required

YES

NO

28A. If Yes, Please Explain.

29. Do you have any type of herpes? * Required

YES

NO

29A. If Yes, Please Explain.

30. Are you sensitive to petroleum-based products? * Required

YES

NO

30A. If Yes, Please Explain.

31. If you have had permanent cosmetics or tattoos, did you have any problems with heaing afterwards? * Required

YES

NO

31A. If Yes, Please Explain.

32. Are you undergoing radiation or chemo-therapy treatments? * Required

YES

NO

32A. If Yes, Please Explain.

33. Are you now, or have you ever been on the acne treatment Accutane? * Required

YES

NO

33A. If Yes, Please Explain.

34. Are you wearing a pacemaker? * Required

YES

NO

34A. If Yes, Please Explain.

35. Do you take prescription medications? * Required

YES

NO

35A. If Yes, Please Explain.

36. Are you anemic? * Required

YES

NO

36A. If Yes, Please Explain.

37. Do you have a history of skin sensitivities? * Required

YES

NO

37A. If Yes, Please Explain.

38. Do you have any medical conditions that have resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure? * Required

YES

NO

38A. If Yes, Please Explain.

39. Do you have allergies to makeup? * Required

YES

NO

39A. If Yes, Please Explain.

40. Do you have dry eyes? * Required

YES

NO

40A. If Yes, Please Explain.

41. Do you intentionally tan? Direct Sun / Tanning Bed? * Required

YES

NO

41A. If Yes, Please Explain.

42. Do you have a history of cancer? * Required

YES

NO

42A. If Yes, Please Explain.

43. Do you have a history of stroke or heart attack? * Required

YES

NO

43A. If Yes, Please Explain.

44. To your knowledge, are you allergic or resistant to over-the-counter-level numbing products such as ELA-Max? * Required

YES

NO

44A. If Yes, Please Explain.

45. Do you hypo-pigment (lack of pigment on the skin)? * Required

YES

NO

45A. If Yes, Please Explain.

46. Are you allergic to hair dyes? * Required

YES

NO

46A. If Yes, Please Explain.

47. Do you have arthritis? * Required

YES

NO

47A. If Yes, Please Explain.

48. Do you have low or high blood pressure? * Required

YES

NO

48A. If Yes, Please Explain.

49. Do you have sinus problems? * Required

YES

NO

49A. If Yes, Please Explain.

50. Have you experienced Hepatitis or Jaundice during the past 12 months? * Required

YES

NO

50A. If Yes, Please Explain.

51. Have you had any surgeries in the past 10 years? * Required

YES

NO

51A. If Yes, Please Explain.

52. Please list your ethnic background (Your ethnic background affects the body, skin and it's response to treatment.) * Required

Aferican American

Asian

Caucasian

Hispanic

Meditrranean

Native American

Other

53. How would you describe your skin? * Required

Sensitive

Normal

Resilient

54. Please List Your Primary Physician.

54A. Please List Your Primary Physician's Phone Number

Thanks for submitting!

SO NATURAL INSTITUTE

OF PERMANENT COSMETICS
664 N New Ballas Rd

Creve Coeur, MO 63141

Office 314.786.5434

Text 314.200.5434

sonaturalinfo@gmail.com

HOURS
Monday ・ 9:00am - 5:00pm
Tuesday・ 9:00am - 5:00pm
Wednesday・ 9:00am - 5:00pm
Thursday:・9:00am - 5:00pm
Friday・ 9:00am - 5:00pm
Saturday・ By Appointment Only
Sunday・ Closed

@ 1994, So Natural Institute. All Rights Reserved.

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