Permanent Cosmetics Client Information Form
This form is required prior to consultation of any permanent cosmetics procedure.
Today's Date *
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First Name *
Last Name *
Date of Birth *
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Street Address *
City *
State *
Zip *
Cell Phone *
Home Phone *
E-Mail Address *
Who Referred You To Us??? -- If it is a friend please indicate who so we can thank them! *
Required
Procedures Desired *
Required
MEDICAL HISTORY - Have you ever had a cold sore? *
MEDICAL HISTORY - If at any time you have ever had a cold sore, it is strongly recommended you obtain a prescription for VALTREX capsules, an antibiotic that prevents cold sores from your physician. I understand that it's use is highly recommended if I desire Lipliner and/or Full Lip Color procedures. -- I understand the risks of waiving the use of Valtrex and choose not to obtain the prescription. *
MEDICAL HISTORY - Have you ever had any type of plastic Surgery? *
MEDICAL HISTORY - Are you considering facial plastic surgery in the future? *
MEDICAL HISTORY - IF YES, what type? If no, please indicate N/A: *
MEDICAL HISTORY - List all surgeries within the past 5 years. If no, please indicate N/A: *
MEDICAL HISTORY - Are you currently under the care of a physician? *
MEDICAL HISTORY - If so, why? If no please indicate N/A *
MEDICAL HISTORY - Physician's Name. If no, please indicate N/A: *
MEDICAL HISTORY - Allergies: Check all that apply and describe and reaction you've experienced. If no, please indicate N/A *
Required
MEDICAL HISTORY - EYES / EYEBROWS: Check all that apply *
Required
MEDICAL HISTORY - LIPS : Check all that apply *
Required
MEDICAL HISTORY - SKIN : Check all that apply *
Required
MEDICAL HISTORY - GENERAL MEDICAL: Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency (HIV), Hepatitis B virus (HBV) and/or any other blood borne pathogens? *
MEDICAL HISTORY - GENERAL MEDICAL: Have you ever been diagnosed by a medical doctor as having allergies? *
MEDICAL HISTORY - GENERAL MEDICAL: Have you ever been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes? *
MEDICAL HISTORY - GENERAL MEDICAL: Are you currently under the influence of any illegal substance? *
MEDICAL HISTORY - GENERAL MEDICAL: Are you currently under the influence of an alcoholic beverage? *
MEDICAL HISTORY - GENERAL MEDICAL: Have you been diagnosed with jaundice within the past TWELVE months? *
MEDICAL HISTORY - GENERAL MEDICAL: Are you currently on any medications that contain blood thinners, such as Aspirin, Ibuprofen, Coumadin? *
MEDICAL HISTORY - GENERAL MEDICAL: Are you currently on any medications for depression? *
MEDICAL HISTORY - GENERAL MEDICAL: Have you taken Accutane within the last 6 months? *
MEDICAL HISTORY - GENERAL MEDICAL: List all the medications, prescriptions, you have taken in the last two weeks. If no, please indicate N/A. *
MEDICAL HISTORY - GENERAL MEDICAL: Do you desire an allergy test? *
I understand the taking of before and after photographs of said procedure(s) are required. *
I give So Natural Permanent Cosmetics or anyone authorizes by So Natural Permanent Cosmetics to take photographs of me before, during/or after the procedure and on subsequent visits. I understand that these photographs may be use to prepare and evaluate for my procedure and if in the judgement of my technician research or education. These photographs and information relating to my case may be published and republished, either separately, or in connection with each other in professional journals, or used for any other purpose which my practitioner may deem proper in the interest of education, knowledge or research. In such event, I will not be identified by name, and I expect no compensation for these photographs and waive all rights to any claim for payment or royalties. I also release So Natural Permanent Cosmetics form any liability in connection with the use of such photographs. I hereby acknowledge that I have read and understood the terms of this release. *
You may use my photographs for advertising purposes *
I give So Natural Permanent Cosmetics or anyone authorized by So Natural Permanent Cosmetics to use my photographs in any of it's prints, electronic publications, marketing or webpage. *
I give So Natural Permanent Cosmetics or anyone authorized by So Natural Permanent Cosmetics to use my photographs in any of it's prints, electronic publications, marketing or web-page. PROCEDURE AREA ONLY! Ex. (eye/brows only) or (lips only). *
I give So Natural Permanent Cosmetics or anyone authorized by So Natural Permanent Cosmetics to use my photographs in any of it's prints, electronic publications, marketing or webpage. FULL FACE *
I hereby acknowledge that I am not under the influence of drugs or alcohol and desire to receive the indicated permanent cosmetics procedure *
The process use to pigment the skin is a multiple step process. Layers of pigment (color) are tattooed into the skin on e layer at a time over multiple visits, spaced no sooner then, four weeks apart. This allows the cells to fully repair themselves. While these injected tones may from time to time simulate the exact color and tone desired, they will not always be perfect matches. This is due to the fact that while natural skin tones vary if the skin is cold or warm or your circulation is good or poor, injected pigments are permanent. This may mean that your lip-line may appear darker on some days or that your eyebrows appear lighter after exposure to the sun. The pigment is placed under your skin and is therefore affected by the ever-changing tones of the epidermis. This is what sets "Permanent Makeup" apart from regular cosmetics, which are placed on top of and cover the epidermis. *
I understand the permanent skin pigmentation procedure carries with it possible complication and consequences associated with this type of cosmetic procedure, including but not limited to: infection scarring, inconsistent color, and spreading or fanning of fading of pigments. I understand that actual color of the pigment may be modified slightly to do the tone and color of my skin. I fully understand this is a a tattoo process and therefore not a science but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s) *
I acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure of tattooing. Such Medical conditions included by are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medications that weaken the immune system. *
I further acknowledge that the tattoo should be considered permanent; that said tattoo can be removed by a removal procedure or a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement. *
I will adhere to all pre-and post-procedure instructions. If I have ever had cold sores, I will take the recommend prescription VALTREX as instructed by the practitioner. Your primary physician should prescribe this for you. *
I understand that taking of before and after photographs of said procedure(s) are required. I certify I have read and initialed the above paragraphs and have explained to my full understanding this consent and procedure permit. I understand that this is consequent form and I agree to be legally bound by it. *
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