Removal procedure form | Rita Makmak Beauty

Laser Permanent Makeup Removal Registration & Consent

Welcome to Rita Makmak Beauty! Please complete this form before your first laser permanent makeup removal session.

Provide your pigment and treatment history, current health information, medications, and allergies. Rita will review your answers and discuss your treatment goals before starting.

Keep Rita informed of any changes throughout your removal treatment course. Please use the same email address you used when booking your appointment. 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

Email Address

Mobile Phone Number

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

How did you hear about Rita Makmak Beauty?

If someone referred you, who can we thank?

Emergency Contact

Emergency Contact Full Name

Relationship to You

Emergency Contact Phone Number

Previous Pigment & Removal History

Is this your first laser removal session with Rita?

Health History

Please provide current information for today’s laser removal session, even if you have completed this form before. Rita will review your answers with you before treatment. If you’re unsure how to answer, please ask Rita.

Do you have any medical conditions, including diabetes, bleeding problems, immune-system conditions, sensitivity to light, or problems with healing or raised scars? List them, or enter “None.”

List your current medications, supplements, medicated skin products, and any known allergies. Include recently stopped medications and any previous reaction to tattoo pigment or numbing products. If none, enter “None.”

Have you had any recent injections, surgery, peels, laser treatments, or other procedures in or near the area being treated?

Are you pregnant, possibly pregnant, or breastfeeding?

Do you have any eye conditions, previous eye surgery or injury, or current eye symptoms? Are you wearing contact lenses today? Please provide details, or enter “None.”