Dear Client,

Thank you for your interest in Mirinka Cosmetic Creations. We appreciate the opportunity to tell you more about "Micro-pigmentation" and the different techniques employed to improve your natural beauty. These procedures have helped thousands of individuals like you to achieve their goals for an outstanding lasting first impression.

You can count on Mirinka Cosmetic Creations for your permanent cosmetics.

Schedule your procedure today! Call us toll free at 1-800-647-4652 between the hours of 9:00 am and 5:00 pm, Monday through Friday.

Click here to print  a copy of our Pre and Post-Procedure Instructions.

Full Name:
Address:
City:
State:
Zip:
Day Phone:
Eve Phone:
Fax:
E-mail:
Contact Method:

 
Date of Birth:
Age:
Occupation:

Whom may we thank for referring you?
 

How did you learn of our practice?
 

Which feature(s) would you like permanently enhanced?
 
Eyebrows
Lip
Areola
Birth Mark
Eyeliner
Beauty Mark
Scar Camouflage
Hair Line
Other:
   

Have you had previous micro-pigmentation?
 
No
Yes

Are you considering plastic surgery?
 
No
Yes

Comments or Questions:
   

Privacy Policy
The information which you provide in completing this form will be forwarded to the designated party for its use and will not be used by Real Pages for any other purpose or given to any other parties.


Confidential Medical Information

Full Name:
Date of Birth:
Age:
Height:
Weight:
Do You Smoke? Yes  No

Please describe the following in details:

Medical Problems:

Medications:

Hospitalizations/Surgeries:

Allergies to Medications:

Have you suffered from, or are you at risk for any of the following?
Heart Condition
Mitral Valve Prolapse
Artificial Heart Valve
Pace Maker
Stroke
Alzheimer's Disease
Fainting/Dizziness
Nervous Disorders
High/Low Blood Pressure
Seizures/Epilepsy
Liver Problems
Kidney Problems
Asthma/Emphysema/TB
Diabetes
Bleeding Disorder

Do you have any metal implant devices?
  Yes  No

Have you ever had problems after an injection of local anesthetics?
  Yes  No

Do you bruise easily?
  Yes  No

Do you have contact lenses?
  Yes  No

Do you have removable dentures?
  Yes  No

Are you prone to cold sores/fever blisters?
  Yes  No

Have you had Botox or Fillers, Silicon (lips, wrinkles, etc.)?
  Yes  No

I hereby certify that all the information is true and correct to the best of my knowledge.
 
Initials:
Date: