Semi-permanent makeup registration - Leyla Skincare and Beauty

Semi-Permanent Makeup Pre-Registration Form

Beautiful results begin with clear and responsible information.

To provide you with a safe, personalized, and professional semi-permanent makeup service, please complete this form before your appointment.

Fill out the form

Your information is confidential

Complete your semi-permanent makeup registration here

Every client and every skin type is unique. To ensure safety, suitability, and the best possible healed results, I need to review your medical history, relevant conditions, allergies, previous cosmetic tattoo experience, and treatment goals. Please read the Informed Consent for Semi-Permanent MakeupInformed Consent for Semi-Permanent Makeup and our Appointment Scheduling and Cancellation Policy before submitting your form.

New Customer: Semi-permanent registration (form)

Customer information

First name

Last name

Phone (WhatsApp)

Birthdate

Address

Address Line 1

Address Line 2

City

Zip code

Which semi-permanent makeup service are you interested in?

Lip Blush

Powder Brows

Treatment selection

Please answer the following questions to have all the information before the appointment.

Is this your first semi-permanent lip makeup procedure?

Yes

When was your last procedure?

What procedure did you have done?

Aquarelle Lips

Full Lips

Neutralization

I'm not sure

Are you looking for:

Color Correction

Shape Correction

Touch-up / Refresh

I'm not sure

Are you currently experiencing dryness, cracking, cold sores, or irritation on your lips?

Yes

Is this your first semi-permanent eyebrow makeup procedure?

Yes

When was your last procedure?

What procedure did you have done?

Microblading

Ombré Brows

Powder Brows

Eyebrow tattooing

Henna

I'm not sure

Are you looking for:

Color Correction

Shape Correction

Touch-up / Refresh

I'm not sure

Do you dye, laminate, or undergo any chemical treatments on your eyebrows?

Yes

Indicate the treatments you apply to your eyebrows.

Medical History and Contraindications

Do you have diabetes?

Yes

Indicate which type of diabetes you have.

Do you have any heart condition or circulatory disorder?

Yes

Indicate which heart disease or circulatory disorder you have.

Do you have any autoimmune condition?

Yes

Indicate which autoimmune disease you suffer from.

Do you have a history of keloid scarring or poor healing?

Yes

Do you have any bleeding disorder?

Yes

Please specify.

Are you currently taking blood thinners?

Yes

Please list the names of the anticoagulants you are taking.

Are you currently taking Accutane / isotretinoin, or have you taken it in the last 6–12 months?

Yes

Are you currently using Retin-A, retinol, tretinoin, or exfoliating acids near the treatment area?

Yes

Do you have any skin condition in the area to be treated?

Eczema

Psoriasis

Dermatitis

None

Other

What type of condition do you have? Please describe it.

Do you have any allergies?

Latex

Lidocaine

Pigments / Dyes

Tropical Products

None

Other

What type of allergy do you have? Please describe it.

Skin and Healing Assesment

How would you describe your skin type?

Normal

Dry

Oily

Sensitive

I'm not sure

Does your skin heal slowly?

Yes

Do you tend to scar easily?

Yes

Do you have frequent irritation, redness, or sensitivity in the treatment area?

Yes

Lifestyle and Habits

Do you smoke?

Yes

Do you frequently exercise or sweat heavily?

Yes

Do you regulary use exfoliants, peels, or active skincre products?

Yes

Authorizations

Do you understand that semi-permanent makeup may require a touch-up session to ensure a long-lasting result?

Yes

Do you understand that healed results may vary depending on your skin type, aftercare, and retention?

Yes

Are you willing to follow all pre-cure and aftercare instructions?

Yes

Do you understand that final approval is subject to a review of your responses on the form and the photographs you may send us upon request?

Yes

Consent and agreement

I confirm that the information I provided is true and complete.

I understand that submiting this form doesn't automatically confirm my appointment.

I declare that I have read and accept the Informed Consent for Semi-Permanent Makeup from Leyla Skincare & Beauty, and I authorize the professional (and her team) to perform the treatment on me in accordance with the professional assessment and criteria.

I authorize the taking of photos and/or videos for clinical registration, monitoring and control, and also for use as promotional material by Leyla Skincare And Beauty on their social networks and website.

I have read and agree to Leyla Skincare and Beauty's Appointment Booking, Deposit, and Cancellation Policy, Terms and Conditions, and Privacy Policy.

I also agree to receive news and exclusive offers.

If you have any questions

If you have any questions before or while filling out the registration, you can write to me directly. Your skin is in good hands.

I have a question