Intake Form

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CLIENT INTAKE FORM

Welcome!

Please click the ▶️ button below when you are ready to fill out our Client Intake Form

First Name *

Last Name *

Date of birth (MM/DD/YYYY) *

Address *

City *

State *

Postal code *

Phone *

May we contact you at this number? *

Yes

Email *

What service are you here for today? *

Are you currently under the care of a physician? *

Yes

Please let us know why are you under physician care at this time? *

Physician's Name

Physician's Phone Number

Are you presently taking any medication which thins your blood? *

Yes

Are you taking other medications? *

Yes

Please list any medications you are currently taking at this time. *

Do you take antibiotics when going to the dentist? *

Yes

Why do you take antibiotics?

Do you have a heart condition that requires premedication prior to any invasive procedure? *

Yes

If Yes, you must contact your physician prior to treatment to get preapproval and medication prior to your treatment.

Are you pregnant or nursing? *

Yes

Please select all that apply (Leave blank if they do NOT apply)

Allergies

Moles or freckles at site of tattoo

Hepatitis

Heart problems

Hemophilia

Diabetes

Skin Problems

Scarring Keloids

Eye Problems

Epilepsy

Other

If you don't see something listed that applies to you, please enter it below.

Click next if none apply

Do you wear contact lenses? *

Yes

How did you find us? *

Referred by a friend/family member

Facebook

Google

Instagram

Date of appointment *

Signature *

Clear

Opening Hours

Monday 9am - 5pm

Tuesday 9am - 5pm

Wednesday 9am – 5pm

Thursday 9am – 5pm

Friday 9am - 5pm

Saturday 9am – 5pm

~~Sunday Closed~~

Contact Information

Address: 9421 Ackman Rd, Lake in the Hills, IL 60156

Email: shay@enviebrowz.com

Telephone: (847) 603-4346