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1412 South 7 Hwy.
Suite E
Blue Springs, MO 64014

Phone:
(816)220-7773
Fax:
(816)220-2272

Email: cindy@merrill
permanentcolor.com

 

Permanent Cosmetics -
Request for Consult

In order to serve your needs better, please complete this consult form. We will determine you suitability for laser hair removal treatment, and our office will contact you within 48 hours with recommendations.

 REQUIRED FIELDS ARE IN RED

Title Mr. Ms. Mrs.
First Name
Last Name
Address
City
State
Zip
Are you over 18? Yes No
Can we contact
you by phone?		 Yes No
Daytime Phone
Evening Phone
EMail Address
   
Area(s) desiring permanent cosmetics: Eyebrows Eyeliner
Lip Color Other
Hair Color: Blonde Brown Red
Black    Grey    Other
Eye Color: Hazel  Brown  Blue 
Green  Other
Skin Tone: Light Toned
Medium Toned
Dark Toned
Do you wear eyeglasses: Yes No
Contact Lenses: Yes No
   
Last Sun/UV (tanning salon) exposure:
Have you ever had a cold sore or fever blister on your lips: Yes No
If yes,
Did you or do you take medication to prevent outbreaks:		 Yes No
Do you currently or ever had any permanent cosmetics: Yes No
If yes: What body area:
Was treatment completed: Yes No
Were you happy with the results: Yes No
Any problems following procedure: Yes No
If yes, Explain:
Any special concerns or extra questions:
   

    

 

 


We maintain a full line of LA ROCHE - POSAY products in our office.  Click HERE for more information.


Directions and a Map to our location can be found HERE.


Check out our supporting sites!


Check Here for Frequently Asked Questions


Click to see our specials from:

FEIST
or
VAL-PAK

 


It is our goal to provide you with professional services to help you look your very best.
 

We offer FREE consultations to all new clients!
$50 value

  

 

 

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