CLIENT INTAKE & MEDICAL HISTORY FORM

CLIENT INTAKE & MEDICAL HISTORY FORM

PARAMEDICAL & COSMETIC MICROPIGMENTATION
Name*

First NameLast Name
Address*

Street Address

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CityState

Zip CodeCountry
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Birth Date

MonthDayYear
Date
Occupation
Referred By
Do you have any Allergies or Sensitivities, including dietary? (List here)
Are you currently on any medications, topical or oral, especially blood thinners? (list here, along with the conditions they are treating)
Have you had/used any recent Exfoliating or Resurfacing Treatments (if yes, please indicate date)
Have you had any recent Facial Waxing (if yes please indicate date)
Have you used any recent Resurfacing Products (Retinol, Retin-A, Accutane; if yes, please indicate date)
Have you had any recent Botox or Fillers (if yes please indicate date)
Have you had any recent Sun Exposure (if yes please indicate date)
Have you had any recent Surgery (if yes please indicate date)
Are you pregnant or breastfeeding?

YESNOACTIVELY TRYING
Do you have, or have you had, any of the following: (PLEASE READ CAREFULLY & THOROUGHLY)

AcneCancerCold Sores / Fever BlistersDiabetesEpilepsyExzemaHeart ProblemsHemophiliaHepatitisHerpesHIV / AIDSHyperpigmentationHypopigmentationInfectious DiseaseKeloids (raised scars)Liver DiseaseMelasma / Pregnancy MaskingPacemakerPigmentationPoor Healing of WoundsPrevious Tattooing on the AreaProlonged BleedingProne to ScarringPsoriasisRosaceaSkin conditionsThyroid conditionTrichotillamania (hair pulling)VitiligoOther
I understand that during subsequent visits it is my responsibility to inform the technician of any updates to the answers I have provided on this form.

I certify that the information above is true & correct and I have not withheld any information requested on this form. I understand that it is my responsibility to inform the technician of any medical or health conditions, as they may affect my treatment. I understand that certain medical conditions, medications, or skin treatments may prove unfit for micropigmentation procedures. Certain medical conditions or medication may require a doctors note before proceeding with micropigmentation procedures. Failure to answer truthfully may result in personal injury. My signature below constitutes my consent to treatment. I hereby give my consent and authorization voluntarily. I release this establishment and its agents from liability for any injury, loss or damage that may result from any information I have withheld.
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Please read the following carefully & sign:

Permanent Cosmetics

Depending on the skin's structure, after the first treatment, small flakes with a loss of some pigment may occur and color intensity may change. Cosmetic procedures require a 2nd session touch-up to achieve optimal results. In the first seven days the area is up to 40% darker and 10-15% thicker than the healed results. This will subside and look more natural once fully healed.The final result cannot be determined until the area is completely healed, around 6 weeks. Upon completion of the procedure there might be slight swelling and redness of the skin, which will subside within 1-2 days. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be avoided until the skin has fully healed. The procedure results will look acceptable to appear in public without additional make-up on or around the area. I agree to follow the After Care Instructions provided perfectly in order to ensure my satisfaction with the final results. I understand that my technician will be taking photographs before and after the treatment for record keeping and liability purposes and that this is necessary if I am to undergo the procedure. These photos may be shared on MolliJo Aesthetics social media accounts and if I wish to remain anonymous I have the right to request my identity be hidden (close-up only, no full face images.)

Paramedical Cosmetics

Depending on the skin's structure, after the first treatment, small flakes with a loss of some pigment may occur and color intensity may change. Treatments require a number of additional sessions to achieve optimal results. This is not a one-session treatment. In the first seven days the area is up to 40% brighter and noticeable than the healed results. This will subside and blend out once fully healed.The final result cannot be determined until the area is completely healed, around 4 weeks. Upon completion of the procedure there might be slight swelling and redness of the skin, which will subside within 1-7 days. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration, exposure to the sun, and exposure of the area to water should be avoided until the skin has fully healed or as guided by aftercare. I agree to follow the After Care Instructions provided perfectly in order to ensure my satisfaction with the final results. I understand that my technician will be taking photographs before and after the treatment for record keeping and liability purposes and that this is necessary if I am to undergo the procedure. These photos may be shared on MolliJo Aesthetics social media accounts and if I wish to remain anonymous I have the right to request my identity be hidden (close-up only, no full face images.)
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MOLLIJO AESTHETICS FEES & POLICIES

PARAMEDICAL & COSMETIC MICROPIGMENTATION
An online consultation (through messaging or email) is offered prior to having the service. This consists of answering relevant health-related questions to ensure it is safe for you to have the treatment done. You will be asked to provide clear and up close photos of the area without makeup.

You may also have a live complimentary consultation in-person at the studio. During this appointment we will take measurements and do a sketch of the shape which we would use as an outline for the actual treatment.

The cost of the permanent cosmetics procedure includes the Initial Session and the 2nd Session, which must be performed 6-12 weeks later. The cost of the paramedical treatment will include 1 session or multiple sessions (if a package is purchased). A card must submitted on file & is required to schedule your treatment. Cards kept on file will not be charged, unless a cancellation or no-show fee is required.

If you cancel the appointment with more than 48 hours notice, you will not be charged MolliJo Aesthetics' cancellation fee.

With less than 48 hours notice, there will be an applied service cancellation fee.

No call, No shows will be charged the service cancellation fee. No call, No Show clients will be required to pay half of the service fee upon rebooking, which is non-refundable with less than 48 hours cancellation notice. After a second no call, no show clients will be required to pay the full service amount upon rebooking, which is non-refundable with less than 48 hours cancellation notice. After a third no call, no show clients will no longer be allowed to book with MolliJo Aesthetics.

Scheduled appointments for the permanent cosmetics included 2nd session touch-up also require 48 hours notice for cancellation or rescheduling. The 2nd session touch-up is included in the original price only when performed within 12 weeks after the Initial Session. After 12 weeks, or if appointments are cancelled or rescheduled with insufficient notice, the 2nd session touch-up will be charged at MolliJo Aesthetics prevailing touch up rate, coving equipment and tray setup fees.

By signing this form, I am acknowledging that I have read and fully understand the policies.
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CLIENT INTAKE & MEDICAL HISTORY FORM

MOLLIJO AESTHETICS FEES & POLICIES