Initial procedure | Rita Makmak Beauty

Permanent Makeup Registration & Consent

Welcome to Rita Makmak Beauty! Please complete this form before your procedure today. Answer each question carefully so Rita can review your information with you before starting.

Please use the same email address you used when booking your appointment and double-check it for accuracy. We’ll use it to send your aftercare instructions and follow-up emails.

First name

Last name

Gender

Female

Male

Date of Birth

Día

Mes

Año

Mobile Phone Number

Email Address

Yes, I’d like to receive special offers, beauty tips, and news from Rita Makmak Beauty by email. I can unsubscribe at any time.

Address

Emergency Contact

Emergency Contact Full Name

Relationship to You

Emergency Contact Phone Number

Health History

Please answer the following questions accurately and include any relevant details. Rita will review your answers with you before starting. If you’re unsure how to answer a question, please ask Rita.

Please provide details about any conditions selected above, including relevant dates, treatment, or anything you would like to discuss with Rita.

Have you experienced slow wound healing or problems healing after a cut, surgery, tattoo, or previous permanent makeup procedure?

Yes

No

Not sure

Have you ever developed thick, raised scars or keloids after a skin injury or procedure?

Yes

No

Not sure

If you answered “Yes” or “Not sure” to either question, please provide details or discuss this with Rita before your procedure.

Have you consumed any alcohol today?

Have you consumed any caffeine today, such as coffee, tea, or energy drinks?

Are you currently taking any blood-thinning medication, such as warfarin (Coumadin), Eliquis, Xarelto, Plavix, or daily aspirin?

Have you recently taken aspirin, ibuprofen (Advil or Motrin), or naproxen (Aleve), including occasional doses for pain?

If you answered “Yes” or “Not sure” to either question, please list the medication, dose if known, and when you last took it.

Do not stop or change any prescribed medication for this procedure without guidance from your prescribing healthcare professional. Please discuss your answers with Rita before treatment.

Are you currently pregnant, or is there a possibility you may be pregnant?

Are you currently breastfeeding?

Are you currently wearing contact lenses?

Have you had any face surgery or medical procedure that Rita should know about before today’s treatment?

If yes or not sure, please describe the procedure, when it took place, and whether you are still recovering.

Do you have any known allergies or have you ever had a reaction to medications, numbing products (such as lidocaine), tattoo pigments, latex, adhesives, antiseptics, or skincare products?

If yes or not sure, please list the substance or product and describe the reaction you experienced.

Please list all medications, vitamins, and supplements you currently take, including prescription medicines, over-the-counter products, and herbal supplements. Include doses if known. If you take none, enter “None.”

Is there anything else about your health, current symptoms, ongoing treatment, or previous experience with permanent makeup that you would like Rita to know before today’s procedure?