Client Registration & Medical History
Email address *
Name *
Date of birth *
Address & Phone # *
Why did you choose Anastasia Brows, Skin, Wellness services? Referral source? *
Have you had permanent make up before? Were you happy with the results? *
Please contact me @ 480-343-8023 for a complementary Zoom/Facetime consultation OR use to send photos. *
Please give details of the desired outcome for your brows, eyeliner, lips: (ie: Shape color etc.) *
Do you have:
Check allergies:
In the past 24 hours do you have a fever, flu-like symptoms. *
List ALL Medical Conditions/Disease(s) past and present. List medications: *
What skin conditions do you have? ie: Acne, Oily skin fever blisters. IF YOU HAVE OILY SKIN - Microblading MAY NOT be advised for your best results. Please discuss with Stephanie if you have oily skin for an alternative option.
Your Initials are required for the following questions.
I understand that FADING or loss of pigment may occur of up to 50%. Results are based on skin condition, medications and compliance to the after care instructions provided by Stephanie. I understand that some discomfort is associated with this procedure and minor and temporary swelling, redness and/or fever blisters/cold sores may occur. Benadryl or another suitable antihistamine may reduce these side effects. I understand that sun, tanning beds, swimming pools, skin care products, medication CT scans affect my permanent makeup. 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:
I have been advised to discontinued all Retin A, Renova or Glycolic Acids using two weeks prior to all procedures. 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.I understand that I must be off Accutane 6 months prior to procedure(s).One year prior for lips. If you choose to continue with the forementioned skin products your permanent make up result may require more than one touch up. Initial:
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) Inform medical providers of your permanent make up. I understand that I am to inform medical personnel about my permanent makeup prior to a MRI. Client has been informed to wait one year following tattoo before donating blood. Initial:
LIPS ONLY- 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. I understand that successful lip saturation/ color retention cannot be guaranteed due to hidden scar tissue. I understand it is my responsibility to obtain a prescription for fever blister medication to help avoid an outbreak from a doctor or dentist. *Fever Blisters can occur with any lip procedure, 90% of the population has this virus! Initial:
I accept full responsibility for explaining to Stephanie my desire for specific color, shape and position for eyebrows, eyeliner and lips. 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:
The nature of the proposed permanent makeup process and procedure has beenexplained to my satisfaction. Initial: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:
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 understand that I can have an allergy scratch test by request prior to treatment. Initial: I certify that I have read and understood all of the above. Initial:
The True Science skin care system is advised to help maintain your permenent make up's longevity. (Use the link below.) Individual or complete system @$25.99-140.99.
For your safety all all guideline given by the CDC, Universal precautions and Osha standards/guidelines are being followed. All products and private room used for your service are pre-sterilized, which include but not limited to new one time use needle tips microblades, pigments, gloves, cotton applicators.
By signing I am agreeing to aforementioned services to be provided by Stephanie. Aftercare products have been provided for me. Oral instruction, along with online instructions have been made available for me I understand that If I do not follow these instructions it may compromise my final results.
I will contact Stephanie with any questions or concerns if any should arise.
I will follow and use the after care products and instructions provided to me by Stephanie.
I understand that I will contact Stephanie immediately if I have concerns following my treatment.
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 @ 6 to 8 weeks is $100.
I understand that the fee for a touch up done @ 6 months to 1 year is $150.
I understand that the fee for a touch up done after 1 year is $200-300 depending on future desired pmu procedure.
All returning clients do receive a reduced price for future refresher color boosts.
I understand no refunds will be given for procedures that I have elected, scheduled and agreed upon.

I thank you for trusting in me for your permanent makeup needs. Please feel free contact me directly if there are any further questions or concerns.
Thank you!

Stetphanie Anastasia

Client Signature *
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