Cosmetic Tattooing Medical History Form

Cosmetic Tattooing Health History Form

Glam Bar Alabama (256)-426-1345 21714 US HWY 431 Guntersville, AL 35976 booking@glambaralabama.com
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number (You will receive a text and/or email reminder before your appointment)
Email *
You will receive a text and/or email reminder before your appointment
How did you hear about Glam Bar Alabama? *

Please answer the following questions: Do you presently have, or have you ever had: *

	YES	NO
1. Hepatitis B?
2. Hepatitis C?
3. HIV/AIDS?
4. Diabetes?
5. History of hemophilia or any other blood disorder/disease?
6. Skin diseases or skin lesions?
7. Sensitivities to soaps, disinfectants, etc.?
8. History of allergies or adverse reactions to pigments, dyes, latex, etc.?
9. Tuberculosis?
10. Immune disorders?
11. History of epilepsy, seizures, fainting, or narcolepsy?
12. Scarring (keloids)?
13. History of heart murmur or any heart disease/condition?
14. History of taking medications such as anticoagulants that thin the blood and/or interfere with blood clotting?
15. Are you under the influence of alcohol or drugs?
16. Are there any other medical conditions which may affect your body art healing process?
17. FEMALES: Are you pregnant or breast feeding/nursing?
18.Have you had any previous cosmetic tattooing?

IF YOU HAVE ANSWERED "YES" TO ANY OF THE ABOVE CONDITIONS, IT IS RECOMMENDED THAT YOU CONSULT WITH YOUR PERSONAL PHYSICIAN OR DENTIST BEFORE ANY PIERCING OR TATTOOING PROCEDURES ARE PERFORMED.

Extreme redness, swelling, pain or seepage are all signs of a reaction or possible infection. This would be rare, but if it occurs, call a doctor immediately!
I declare that I am over the age of 18, not under the influence of drugs or alcohol, not pregnant or nursing, not on blood thinners or blood pressure medication, and am not an insulin-dependent Diabetic. I understand that many medications and some diseases and disorders may either contraindicate me for treatment or affect the results. I understand I should continue taking my medications, and tell my technician about all prescription and nonprescription drugs, supplements, topically applied products, eye drops, etc. that I use or take. I understand permanent makeup is a tattoo process; it is not an exact science, but an art. I have been informed of the general nature of permanent makeup and the specific nature of the procedure(s) described above.

Risks of Procedure(s): I understand there are risks associated with permanent makeup, including, but not limited to: Infection: Procedures which involve penetrating the skin could cause infection; Scarring: Recovery from the procedure(s) could lead to scarring; Allergic reaction: Pigments, dyes, or other materials used could cause a reaction; Color: Colors will vary based on skin tone, pigments may fade over time; Irregularity: Pigments may fan or spread, causing makeup lines to blur; Corneal Abrasion: Rubbing or scratching eyes or applying contacts shortly after an eyeliner procedure could cause an abrasion; Permanence: Permanent makeup is intended to produce long-lasting changes to appearance which may be difficult or impossible to modify or remove.
Pre Procedure Instructions:
- Do not take blood thinning medication (aspirin, niacin, vitamin E, fish oil, or ibuprofen for one week prior appointment
- no caffeine, alcohol, or energy drinks within 24 hours -increases the risk of bleeding
- brow waxing & tinting and lip waxing must be performed 7 days prior and 6 weeks after
- no chemical peels or exfoliating facial treatments 1 month before and 2 months after
- stop using lash growth serums 1 month before and after
- For lash liner, you should remove your contacts since your eyes will be gently manipulated
- For lash liner, you should be lash extension free before and during your appointment
- Come to your appointment makeup free on the area receiving PMU
Aftercare Instructions:

Permanent Makeup is life-changing, but does require some maintenance from you after you leave the studio to ensure your lips, eyebrows, and/or eyeliner heals beautifully!
- No heavy sweating for 10 days after the procedure
- No skincare, makeup, creams on area (except for provided aftercare ointment) until healed
- Apply ointment very sparingly to area (rice grain sized amount)
- No steam, hot baths, sauna, hot tub, swimming, pools until flaking is complete & healed
- No sunbathing or tanning for 4 weeks after procedure
- Protect the area from sun exposure when in direct sunlight
- No facials, chemical peels, botox, dermabrasion, or other strong exfoliants/treatments until fully healed
- For eyebrow & liner procedure, avoid eyelash and eyebrow tinting/lifting, waxing, electrolysis, and tweezing until healed
- No abrasive products (rough towels, wash cloths, etc.)
- Do not scratch or pick at area (flaking needs to fall off on it's own)
- Call, text, or email us if you have any questions!
- Extreme redness, swelling, pain or seepage are all signs of a reaction or possible infection. This would be rare, but if it occurs, call a doctor immediately!
  *Aftercare is provided at appointment time
Pre-Procedure and Aftercare Instructions: I will strictly adhere to, all pre-procedure and
aftercare instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.
Sign below that you understand & agree to follow these and all pre-procedure and aftercare instructions provided: *

Clear

Please answer the following questions: *

	YES	NO
Are you taking any Blood thinning medication?
Are you under 18 years of age?
Do you have any Skin irritations on or near the area including, but not limited to- sunburn, psoriasis, acne, rashes, blisters, etc.?
Are you pregnant, planning to be pregnant in the next 4 months, or breastfeeding within the last 3 months?
Are you taking or have you taken any sun-sensitizing medications or skin exfoliating products including, but not limited to- Retinoids, Vitamin A, Accutane within the last 6 months?
Are you undergoing or have been undergoing chemotherapy within the past 6 months?
Are you Diabetic?
Do you have any skin diseases?
Do you have glaucoma?
Do you have or have you had Botox and filler within the last four weeks?
Do you have or ever have had a history of keloid scarring?
Do you use or have you used Eyelash-growth serums like Latisse within the last month?
Do you have or have ever had a pacemaker?
Do you have or have ever had shingles?
Do you have or have you ever had any auto-immune disorders and/or deficiencies?
Do you have or have you ever had a history of fever blisters or cold sores?
Have you had chemical peels or strong exfoliating facial treatments within the last month?
Have you had Cosmetic facial surgery within the last month?
Do you have or have you ever had previous permanent tattoo work?
Do you or have you ever had acne in the brow area?
Do you or have you ever had bleeding issues including Hemophilia or clotting issues?
Do you have eyelash extensions?
Do you have moles, milia, or spots inside the desired procedure area?
Do you have oily skin?
Do you have any dermatological disorders or diseases including eczema?
Do you have any allergies? including but not limited to latex, lidocaine, metals, glycerine

* DISCLAIMER: It is required that the client consult with their Physician prior to taking, altering, or stopping any form of medication and/or supplements, or making changes to their dosing cycles, diet, etc.
Prior Permanent Makeup
By consult only. Sometimes we cannot work over other artists' work. Please contact us to discuss BEFORE booking. If you have EVER had permanent makeup before (even if it has completely faded), you must let us know prior to booking so we can ensure that it can be covered. Failure to do so may result in disappointment and loss of deposit if you arrive to your appointment and it cannot be covered.
Payment Policy
Glam Bar Alabama accepts all major credit cards, debit cards and cash. No checks or money orders. All permanent makeup appointments require a non-refundable $100.00 booking deposit to book. This booking fee goes toward your total investment and holds your spot on the calendar. Please call, email, or text to book your appointment, or book online. After selecting a date and time, you will receive instructions for paying your deposit by debit or credit card by email. Your appointment is not booked until you have paid your deposit. Please review our cancellation policy below prior to booking.
Cancellation Policy
Please read this policy before booking any appointments at Glam Bar Alabama to make sure you fully understand. The reason for this policy is that we remain very booked for all services, with some clients waiting months to be seen. While we are ever so grateful for our wonderful clients, timely and efficient service is necessary for us to provide outstanding customer service. If you fail to comply with these policies, we are unable to service everyone in a fair and efficient way. Customer satisfaction is our highest priority, and these policies exist to give all clients the absolute best experience possible. We are so thankful for your business and welcome any inquiries about this policy!

For all permanent makeup appointments, a 72-hour notice is required to cancel or reschedule your appointment. Should you fail to cancel or reschedule your appointment at least 72-hours before your appointment, you will forfeit your booking deposit. Should you wish to reschedule your appointment at that point, you definitely can! You will have to pay another non-refundable deposit to book another date.
Late Policy
If you are over 10-minutes late to any appointment, you will be asked to reschedule, and the same policies above will apply. This is because all clients receive thorough consultations and detailed, precise work. As a result, we will not omit vital steps or rush your appointment or others. Therefore, if you are more than 10-minutes late to your appointment, you will forfeit your deposit and be required to pay another non-refundable deposit before you can re-book.There will be no exceptions to this policy. By booking your appointment with Glam Bar Alabama, you acknowledge that you have read, understand, and agree to the Cancellation Policy.
Your Compliance
All permanent makeup procedures are a 2-step process: The initial appointment and the 6-week touchup appointment. By omitting your 6-week touchup appointment, you are not fully completing the process.

Touchups are a required part of the permanent makeup process as it is very difficult to predict how well the skin will retain the pigment. If you have things you do want to tweak after the first appointment, no worries! The brows may needs more strokes added or maybe one specific area did not take the pigment well. The color may need an adjustment or the client may just want to go darker. Other reasons that touchups are required are to ensure as much symmetry as possible with your bone structure. At the touchup, we can also adjust things like: one brow tail appearing shorter or higher/lower than the other from healing, or going overall darker with your PMU. These are all minor imperfections that are easily fixed at the 6-week touchup appointment. We will continue to work on your brows at the touchup appointment! Even if you love your brows, lips, or liner, the touchup is vital to the final complete result!

If you do not schedule and omit your required 6-week touchup appointment, please understand that pricing will be reflected based on how long it has been between your initial and touchup appointment.

If you had your initial Permanent Makeup appointment done by Glam Bar Alabama and chose to go elsewhere for your touchup because you failed to maintain your appointment, please understand that I will no longer service you!
Have you read all of the Policies page and this form? If you make a deposit today you are stating that you agree to all of Glam Bar Alabama's policies, including Late Arrival fees, Cancellation or Reschedule Fees, No-Show Auto Charges. Type "I AGREE" below *
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please select any and all Semi - Permanent Tattoo Type(s) you are interested in now or in the future: *

Microblading/Shading Lip Blush Eyeliner Enhancement Touchup - Microblading/Shading Touchup - Lip Blush Touchup - Eyeliner Enhancement
Please select Semi-Permanent Tattoo Artist *

Kennedy Kirkland
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Cosmetic Tattooing Health History Form

IF YOU HAVE ANSWERED "YES" TO ANY OF THE ABOVE CONDITIONS, IT IS RECOMMENDED THAT YOU CONSULT WITH YOUR PERSONAL PHYSICIAN OR DENTIST BEFORE ANY PIERCING OR TATTOOING PROCEDURES ARE PERFORMED.