Client Registration & Medical History
INFORMATION
Email address *
Name *
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Date *
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Address *
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City *
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Zip Code *
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Phone Number(s) *
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Age (Must be 18) *
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Driver’s License # *
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Emergency Contact Name *
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Emergency Contact # *
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Email Address *
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Referred By?
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Why do you want permanent makeup/skin care?
Your answer
*
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Physician’s Name
Your answer
Please list any prescription meds, herbs or vitamins you are taking.
Your answer
Choose those that apply
Have you recently had or plan to undergo any elective or necessary facial surgery or laser procedures?
Your answer
Do you have any knwon allergies?
Your answer
Choose all that apply:
Choose any that apply:
Do you have a Dermatologist?
What skin conditions do you have?
Your answer
What skin care products are you using?
Your answer
Would you like to discuss treatments to improve the conditions of your skin?
To save your permanent makeup I advise Anti-aging cream True Science system. Scientifically proven to slow down the aging process and prevent skin cancers. Ask me for information.
Circle AND Initial If you have/ had any of the following and explain.
Please explain the conditions selected above and any other conditions not listed:
Your answer
What would you like to achieve with your permanent makeup?
Your answer
I have consulted with my doctor/injecting provider prior to having permanent makeup applied by Stephanie. Have you ever had permanent makeup before?
If Yes, by whom? What procedure and when?
Your answer
Were you pleased with the result of you work?
If not, why?
Your answer
I have discontinued all Retin A, Renova or Glycolic Acids using two weeks prior to all procedures. Initial:
Your answer
Client understands laser treatments, sun and tanning beds can fade makeup or turn color black! (Please do not have any of these done before or after permanent makeup) Initial:
Your answer
Do you need to take Antibiotics prior to seeing your dentist?
Client understands they must be off Accutane six months prior to all procedures! One year for lips. Initial:
Your answer
If you have a history of fever blisters or cold sores you must take an antiviral medication orally before and during any lip tattoo procedures. *Fever Blisters can occur with any lip procedure, 90% of the population has this virus! Initial:
Your answer
Consent for Permanent Makeup
I understand that some discomfort is associated with this procedure and minor and temporary swelling, redness and/or fever blisters/cold sores may occur. Initial:
Your answer
I understand that fading or loss of pigment may occur. Initial:
Your answer
I understand that Permanent Makeup is a multi-session PROCESS requiring more than one visit to perfect most cases. All procedures take at least 30 to 45 days to heal and evaluate. Some may need only one session. Initial:
Your answer
I understand that sun, tanning beds, swimming pools, skin care products, medication CT scans affect my permanent makeup. Initial:
Your answer
I understand that Retin A or Renova must not be used around the treated areas long term. I must stop using 2 weeks prior to my sessions. These products can fade permanent makeup. Initial:
Your answer
I understand that I must be off Accutane 6 months prior to procedure(s).One year prior for lips. Initial:
Your answer
I understand that successful lip saturation/ color retention cannot be guaranteed due to hidden scar tissue. Initial:
Your answer
I understand it is my responsibility to obtain a prescription for fever blister medication to help avoid an outbreak from a doctor or dentist. Initial:
Your answer
Client has been informed to wait one year following tattoo before donating blood. Initial:
Your answer
Client has been advised to inform all skin care and cosmetic professionals and medical personnel about their permanent makeup prior to treatment. Please have them put a protective barrier over all procedures to protect from adverse outcome. Initial:
Your answer
I understand that I am to inform medical personnel about my permanent makeup prior to a MRI. I use non-iron oxide pigments, therefore it should not affect an MRI. Initial:
Your answer
I accept full responsibility for explaining to Stephanie my desire for specific color, shape and position for eyebrows, eyeliner and lips. Initial:
Your answer
I understand that implanted pigment can turn color or fade over time due to circumstances beyond the control of Stephanie and alter the original pigment color. I understand that I will need to maintain the color with future applications. Sun, skin care products, pools and other factors play a role in pigment fading on the face. An allergic reaction can occur, most common with topical and after care. Initial:
Your answer
The nature of the proposed permanent makeup process and procedure has beenexplained to my satisfaction. Initial:
Your answer
I acknowledge that the proposed procedure(s) all involve risks and the possibility of complications during and following the procedure(s). I also acknowledge the risk of infection, misplaced pigment, poor color retention, hyperpigmentation, corneal abrasions,fever blisters and/or allergic reaction. Initial:
Your answer
I hereby consent to having permanent makeup applied by Stephanie with the method of her choice. I have answered all questions truthfully and to the best of my knowledge. I certify that I have read and understood all of the above. Initial:
Your answer
I understand that I can have an allergy scratch test by request prior to treatment. Initial:
Your answer
I accept and agree to the color, shape and design suggested by Stephanie. Initial:
Your answer
I understand TrueScience Skin care system extend the life of my Permanent Makeup. Initial:
Your answer
For your safety all Universal precautions and Osha standards/guidelines are followed. All pre-sterilized needles, pigments, gloves and products will be used for all procedures.
Payment(s) and Signatures:
Notes:
Your answer
I was given before and after instruction, explained orally, online instruction and or a written copy has been made available for me and I will follow to the best of my ability.
Please contact Stephanie Watson with any questions or concerns.
I understand that I will contact Stephanie immediately if I have concerns following treatment.
I understand there will be no refunds for procedures that I have elected, scheduled and agreed upon.
I understand that it is advised that I have a PMU touch up done AFTER 6 weeks as needed.
I understand that I am responsible to schedule a PMU touch up, if I desire one.
I understand that the fee for a touch up done within 120 days or 6 months is $100.
I understand that a reduced price from total fee may apply after 6 months of initial service procedure.
All returning clients receive a reduced price for future refresher color boosts.
Again, please visit contact me directly if you have any further questions or concerns.
Thank you!
Client Signature
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