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Home
Services
Eyebrows
Eyes
Lips
Dark circle concealer
Magnetic Tattoo Removal
Paramedical Men
Paramedical Women
Our stars
Resources
Our videos
Bio
Blog
FAQ
Process
Products
Information form
Consent
Contact
Contact Us
Free consultation
Clinic appointment
Free consultation
Fr
INFORMATION FORM
forms
CONSENT
|
CONSULTATION FORM
|
TOUCH UPS
First Name
Last Name
Phone
Email address
Address
Address
City
Québec
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Zip Code
I was referred by:
I heard about you on:
I am interested in:
Eyes
Eyebrows
Lips
Dark Circle Concealer (scars, dark circles, or other)
Hair loss alternatives
Date of birth
MM slash DD slash YYYY
Occupation and hobbies
(Required)
Do you suffer from heart problems?
(Required)
No
High blood pressure
Low blood pressure
Mitral valve prolapse
Pacemaker
Do you suffer from diabetes?
(Required)
Yes
No
Do you suffer from hepatitis?
(Required)
Yes
No
Do you suffer from HIV?
(Required)
Yes
No
Do you take medication?
(Required)
Yes
No
Specify:
Do you become numb easily, for example at the dentist?
(Required)
Yes
No
Specify:
Do you have any physical disabilities?
(Required)
Yes
No
Specify:
Do you suffer from allergies?
(Required)
Yes
No
Specify:
Do you have permanent makeup or tattoos?
(Required)
Yes
No
Précisez
To better understand you, please check all that apply to you
Oily skin:
Acne
Comedones (blackheads)
Excess shine
Uneven skin texture
Dry and/or dehydrated skin:
Flaking (peeling)
Tightness after showering
Persistent tightness
Dryness fine lines
Skin irregularities:
Psoriasis
Eczema
Moles
Freckles
Sensitive skin:
Visible blood vessels
Red and rough areas
Redness
Pain
Swells quickly
Bruises easily
Skin 55+:
Visible expression lines
Thin-looking skin
Wrinkles
Spots
Your eyes:
Dry
Sensitives
Water easily
Contact lenses
Have you undergone eye surgery?
(Required)
Yes
No
Specify:
Do you suffer from glaucoma?
(Required)
Yes
No
Your lips:
Dehydrated
Naturally pale
Visible asymmetries
Irregular contour
Have you ever had herpes (cold sores, fever blisters)?
Yes
Never
Before proceeding with permanent lip makeup, we recommend that anyone who has previously had a lesion request Valtrex from their doctor or dentist (a preventive medication for cold sores).
Your hair:
Partial alopecia
General alopecia
Thin
Scars
Photos of you that could help us get to know you better:
Drop files here or
Select files
Max. file size: 1 GB, Max. files: 3.
Your habits
Creams and treatments used:
Makeup usually applied:
Your expectations for the appointments with Josée, or any other relevant information.
Date
(Required)
MM slash DD slash YYYY
Signature
CAPTCHA
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