Permanent Makeup New Client Form

Permanent Makeup New Client Information

Take photo of Drivers License, or ID*

NAME*

ADDRESS*

PHONE # *

EMAIL*

example@example.com

DATE OF BIRTH

Date

Do you presently have or previously had any of the following (Y or N) :

Botox

Diabetes

Lip Fillers

Cold Sores/Fever blisters*

Eyelid Surgery

Hepatitis (A, B, C, D)*

Brow lift or Face Lift

Easy Bleeding

Abnormal Heart Condition

Chemical Peel if so last treatment date

Date

Contact Lenses Now

Accutane or Acne treatment

Tan by booth or sun

Difficulty numbing with dental work

Taking blood thinners such as Aspirin, Ibuprofen, alcohol, Coumadin etc.

Very Oily Skin

Currently Pregnant or Breastfeeding

Currently Under the influence of Drugs/Alcohol

List any Known Allergies

List any Diseases or Disorders not listed

Please List Medications or Vitamins you are presently taking

I agree that all the above information is true and accurate to the best of my knowledge.

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Statement of Consent (initial each)

Aftercare instructions have been explained to me and a written copy will be given to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email my technician.*

Email

I understand that a certain amount of discomfort can be associated with this and that swelling, redness and bruising may occur.*

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I understand that sun, tanning beds, pools, medications and some skin care can affect/fade/change color to my permanent makeup or tattoo.*

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I will tell all skin care professionals or medical personnel about my permanent procedures, especially if I'm scheduled for an MRI. I accept the responsibility in to you my desire for specific color, shape, and positions for any procedure today.*

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I acknowledge that the proposed procedure(s) has the possibilities of complications during and/or following the procedures such as : risk of infections, pigment, excessive bleeding, poor color retention, hyper or hypopigmentation, trauma, injury or pain. If an infection or severe reaction occurs, I will go to my physician immediately but will not hold my technician or the company services are performed at accountable for any negative reaction. *

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I accept full responsibility for the decision to have this work done. I fully understand there is NO REFUND, and this procedure may or may not have the outcome I expected. I certify that I have read the contents of this form. I understand the risks and alternatives in this procedure(s) and I have had the opportunity to ask questions and get them answered. | acknowledge that I have reviewed and approved the material and give authorization for Louisville Beauty & Wellness as my permanent cosmetic/tattoo artists/technician to perform my appointment.*

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PERMANENT MAKEUP CLIENTS: I understand that implanted Permanent Makeup pigment color can slightly change or fade completely time due to circumstances beyond anyone's control and I will need to maintain the color/shape with a PERFECTING session 6-8 weeks after initial session and a COLOR REFRESH session before my has work has completely faded (usually between 12-24 months to where the artist can still see the strokes/shape) in order to keep my work crisp and defined. If technician can still see shape of initial work, my color refresh will be about half price of the full priced service. If technician cannot fully see shape originally mapped out, the full service price will be charged at time of refresh. *Essentially--do not let your color fade so much that the artist can't see it before you book a color refresh.

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Consent and Model Release Agreement for Permanent Cosmetics Procedure

This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetic and microblading application. If you have questions, please don't hesitate to ask. Although permanent cosmetic tattooing and microblading are effective in most cases, NO guarantee can be made that a specific client will benefit from the procedure. Microblading is not permanent. There are no refunds.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. A perfecting touchup is generally needed 45-60 days after the healing is completed. YOU MAY NEED MORE THAN ONE PERFECTING TOUCH UP. This can vary due to skin type and following aftercare properly.

SESSION TO ACHIEVE DESIRED RESULTS. MICROBLADING LASTS 6 MONTHS TO

24 MONTHS ON AVERAGE. RESULTS VARY PER PERSON. You are SIGNING this

KNOWING that color retention is NOT guaranteed.

Photography and Videography Release :

Before and After photos/videos may be taken and kept on file. We would like your permission to use these photos/videos for advertising of ANY kind. We do recommend coming in makeup and we will remove the necessary areas if you would like to look your best for your before/after images.

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Results/Outcome Disclosure

It has been reviewed multiple times that my color MAY FADE SIGNIFICANTLY and

will also FADE IN AND OUT DURING THE ENTIRE HEALING PROCESS.

TATTOOS, MICROBLADING AND PERMANENT COSMETICS PROCEDURES ARE NOT FOR EVERYONE, I MAY BE ONE OF THEM.

RESULTS vary (EVEN AFTER HEALING) depending on but not limited to :

how your body metabolizes the color, environmental factors, sun exposure (even after healing), tanning (tanning bed or direct sun even after healing), SMOKING ( this is big one), skin care products/makeup herbal supplements, underlying OR undiagnosed medical conditions, use of certain medications, hormones, not following ALL instructions, unknown causes (which are beyond any person's control), PICKING OR SCRATCHING TREATED AREA, LAKE WATER/ CHLORINATED POOLS AND HOTTUBS (even after healing), chemical peels, microderm treatment, anti-aging treatments, plucking, waxing, threading on treated area, pregnant OR nursing. Microblading and permanent cosmetics are a superficial, semi-permanent treatment. It is implanted in my lower layer of my epidermis which is continually exfoliating. Everyone exfoliates at different rates.

Microblading and Permanent Cosmetics is NOT permanent and may last 6 months to 24 months realistically but could fade sooner or last longer depending on the above points that I have read through and agree to move forward with my procedure. Tattoos are permanent but can need maintenance based on the area selected, the color of pigments chosen and the individuals skin type. Fingers, hands and feet are specifically hard to retain but depending on the person, skin type, aftercare, sun exposure, etc. any tattoo can and will fade. If it does, you can schedule a color boost session (generally about half the price of the original service so long as we can still see and use original work as a guide).

To whom this contract may concern, I have carefully read and understand EVERYTHING I have signed and have had all my questions answered, I am choosing to proceed on my own free will and am in a healthy state of mind to do so. I have viewed the risks and complications, contraindications and followed my pre-care instructions and will follow my post care instructions as well.

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Under 18 years of age (16 with parental consent)*

Y or N

Diabetes (with doctor's permission)*

Y or N

Pregnant or Lactating women*

Y or N

Glaucoma*

Y or N

Skin diseases such as psoriasis, eczema and undiagnosed rashes or blisters on the site that is to be treated, keloids (patch test may be requested)*

Y or N

Easily triggered post inflammatory hyperpigmentation

Y or N

transmittable blood conditions like HIV or Hepatitis

Active skin cancer in the area to be tattooed*

Y or N

Actively in chemotherapy (it is ideal to book these services 6 -8 week prior to treatment to avoid any hair loss looks to the brow that you might be concerned with allow time for your perfecting session). If receiving after chemo, you should at least be a few weeks post chemo and get your doctor's approval.

Y or N

Hemophiliac

Y or N

Healing disorder

Y or N

Blood thinners

Y or N

Uncontrolled high blood pressure or mitral valve disorder

Y or N

Accutane or steroids

Y or N

Active shingles

Y or N

Sunburn on the area getting work

Y or N

Anemia or other abnormal bleeding conditions

Y or N

autoimmune disease (ok with doctors note of clearance)

Y or N

EXISTING TATTOO OR COSMETIC WORK ON DESIRED PROCEDURE AREA (will have to see and determine if work can be done or if tattoo removal needs to be done first--schedule a consultation or text message pics prior to appointment for this)

Y or N

*Let me know if you have/had allergic reactions to topical anesthetics.

Flu, Cold, Fever Please stay home, reschedule your appointment if you have a cold or flu or sinus/respiratory infection *we will take no-contact forehead temperature checks before administering services to keep everyone protected and our environment safe for all of our clients and employees.

Eye lift or blepharoplasty :Wait about 3 months

I do not have any of the contraindications listed above or have my doctor's direct approval to proceed with permanent makeup services.

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Possible Risks and Complications

Excessive bleeding, which can affect results. Excessive bleeding can be due to many factors beyond technician's control.

Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. We will do our very best to keep you comfortable throughout the procedure.

Infection: Infections are very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. Should any sign of infection occur, contact your physician immediately (Pus/oozing, extreme redness, swelling, heat to the area are all signs of infection).

Uneven Pigmentation or poor color retention: This can result from poor healing, infection, bleeding. Excessive scabbing, picking scabbing or many other causes. Your follow up appointment will likely correct any uneven appearance.

Asymmetry: Every effort will be made to avoid asymmetry but our faces are not symmetrical so keep this in mind as we do our work. Adjustments may be needed during the follow up session to correct any unevennessfrom the first session and we will get things as close to symetrical as possible.

Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help with the bruising and swelling will typically disappear within 1-5 days.

Eye Exposure: There is a small risk of eye injury when an eyeliner procedure is performed. To avoid corneal abrasion, Celluvisc, a thick eye drop is used to protect the eye prior to the procedure. Eye drops are used to cleanse and flush the eye after the procedure is complete.

Anesthesia: Topical anesthetics are used to numb the area to be tattooed if cosmetic procedure is being done. Numbing can be added as an additional service/fee if requested for body art tattoos. Lidocaine, Prilocaine, Benzocaine. Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.

MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low-level magnet may be required if you need to be scanned by an MRI

Fever Blisters: If you are prone to cold sores or fever blisters, (herpes simplex), there is a high probability that you will get them lf getting a service on the lips. It is advised that you call your doctor for a prescription antiviral in advance to help prevent his from occurring. We recommend taking this 5 days before and 5 days after a lip procedure is done as a precaution. There still in no guarantee you won't get a breakout, but this has been extremely effective in avoiding them with this procure and is HIGHLY recommended.

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Permanent Cosmetic Pre-care

It is absolutely crucial that you follow your Pre-Care AND Post-care instructions

to achieve the full and best result.

Do not work out for 24 hours before or after procedure NO alcohol or caffeine 48 hours before procedure. Smoking also makes you a heavier bleeder so if you can refrain or cut back prior to appt, you will have bettter results. Avoid sun and tanning one week prior and 2 weeks after procedure. Do not take Aspirin, Niacin, Vitamin E or Advil/Ibuprofen 48 hours before procedure. Avoid Fish Oil for 1 week and Prenatal Vitamins, Nutritional Shakes 48 hours prior to procedure. Discontinue Retin-A, Chemical and Laser Peels, microdermabrasion, and Alpha Hydroxy Acid (AHA) for at least 3 weeks prior (and avoid on eyebrow area after procedure to prevent premature fading) Botox and filler on the forehead, temple and eye area should be avoided 2 weeks prior to AND 2 weeks after procedure in that same area. Avoid ginger, cinnamon, garlic, black and cayenne pepper for 48 hours. You will be more sensitive during your menstrual cycle. Consider this when booking your appt.

Please plan all procedures 1-6 weeks prior to a special event or vacation. This allows adequate time for healing. Your desired brow cannot be achieved in just one session, it is a 2-step process and is not uncommon to lose 30% to 80% of your color after the first treatment. Some clients (few) need MORE than two sessions to achieve their desired density and shape. If excessive bleeding occurs, extra appointments may be necessary for desired outcome.

PERMANENT COSMETICS: Your perfecting session should be done at the 6-8 weeks mark after your work from your first session has fully healed. This is to correct any initial pigment that didn't take and to add more color or shape if desired after seeing how you heal and to layer the pigment for longer overall retention. The perfecting session is $150. We will evaluate and discuss any necessary/requested changes at that time (darker, fluffier, etc).

It is absolutely crucial that you follow your Pre and Post-Care instructions to achieve the full results of the procedure. If directions are not followed, there is a risk that your procedure results won't last as intended. Scabbing is normal. The amount of scabbing cannot be predicted as each person is different. Excessive bleeding can cause excessive scabbing. Blotting the day of will reduce the risk of scabbing and give a better healing process. Washing with hot water and gentle soap (Dial antibacterial, Dove, Baby Shampoo, Cetaphil are all good choices) the evening after procedure and morning next day (or if body art tattoo the when you remove Tegaderm) as well as and day and night everyday for 2 weeks post procedure will also reduce scabbing, prevent infection and promote healing. Blot (do not rub) dry. It's also imperative to your healing process to apply provided ointment in thin layers repeatedly throughout the day and at bedtime. If you weren't provided ointment for any reason or run out before 2 weeks, you can purchase A & D ointment at most local drug stores.

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Typical Healing Schedule

Day 1-4- Areas treated become darker and more filled in looking as they form a scab. This is only temporary, DO NOT PANIC. They will be much darker and fuller looking as scabs form.

Day 5-12- Scab naturally exfoliates, peels and flakes away over the course of several days. The fresh skin underneath is white or pinkish and may have a waxy coating, making it appear that the brows are too light. It may seem like ALL your color has fallen off! Be patient as this is part of the natural skin healing process--

the final outcome will be wonderful.

Day 10-30- After 10 days you may use brow makeup very gently if you need it. The color will slowly come back to life and bloom back to the surface as the new, milky layer of skin settles in and heals. Wait at least 4 weeks to see the true color, it will take on new strength, and it is only after 4 weeks that your touch-up/adjustment can be done. Your second appointment is to tighten up your shape, touch up any light spots, assess how your skin reacts to the process, and decide if you are happy with the chosen color or would like to 90 darker.

NOT EVERYONE FOLLOWS THE EXACT HEALING SCHEDULE. THIS IS ONLY THE AVERAGE HEALING. ALL SKIN IS DIFFERENT AND YOUR BROWS AND PERMANENT

DO NOT FADE. IT MAY TAKE MORE THAN ONE TOUCH UP TO ACHIEVE MY

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For the first 24 hours, blot any fluid from the treated area with a tissue or gauze pad. Scabbing is normal. Some scab more than others for a variety of reasons such as bleeding, or the body's own immune reactions. DO NOT PICK!

1st day (OR 1st day of removing Tegaderm if body art tattoo), VERY IMPORTANT Rinse the treated area (VERY GENTLY) a few hours after procedure then 2x per day for the next 2 days with hot/warm water and gentle, neutral soap (Dove,Cetaphil, Baby Shampoo or Antibacterial Dial) to prevent wound from getting dirty/infected and lessen scab formation. Apply a very thin layer of aftercare ointment each time you rinse. Make sure treated area is COMPLETELY dry before applying ointment (pat dry-do not rub with paper towel or air dry).

Day 2-8 Maintain Hygiene. Morning and Night dab using a cotton pad and sterile water to keep area clean. Apply aftercare ointment very sparingly 3-5 times a day to dry pmu/tattoo. No Makeup or skin care should be applied to brows or area treated.

Day 1-10 Limit showers to 5 mins and avoid too much water on treated area. Avoid pools, saunas, steam rooms, hot showers and or hot baths for 10-14 days.

Do not rub, pick or scratch the treated area. Let any scabbing or dry skin naturally exfoliate off. Picking can cause scarring and pigment loss! Tap or apply ointment if itchng.

Avoid sun exposure and tanning beds for a minimum of 2 weeks after your procedure. Direct sunlight can cause the pigment to change color while healing and can also cause hyperpigmentation and scarring. After 14 days or once the area has healed completely, use sunblock when going out in the sun to stop the color from fading.

Avoid Sweating on treated area for 10 days. Sweating through or on the brows will expel pigment from the dermis producing poor results. If you must workout, choose something that won't have you sweating from the area worked on and avoid cardio, hot steamy showers, baths, saunas and hot tubs.

Avoid sleeping on your pmu/tattoo for the first 10 days!

ALWAYS Avoid Retin-A, Chemical Peels, Laser Treatments, Microdermabrasion, and/or anything to treat hyperpigmentation on/around the treated area to prevent fading.

Type "I Agree" if you agree and consent to our Cancellation Policy*

At Louisville Beauty and Wellness, your appointments are very important to us and we understand that sometimes appointments need to be re-scheduled or canceled. Because most of our services require preparation time to properly prepare a room for your treatment, we have Cancellation Policies in place. In order to provide you and others with excellent customer service and access to appointments during peak times, we kindly ask for the following considerations: CANCELLATION POLICY & FEES: We respectfully request AT LEAST 48 hours notice to cancel or reschedule your appointment but ideally we prefer one full week in order to have the time to fill that spot with someone else. Less than 48 hours notice will result in a charge equal to 100% of the reserved service amount. 50% of that will be applicable to reschedule another (or the same) service within one year. The other 50% will be forfeited for the artist’s time. All "NO SHOWS" will be charged 100% of the reserved service amount to be forfeited for the artist’s time/room setup. This cancellation policy allows us time to inform our standby guests of any availability. Without sufficient notice, we end up turning away other clientele who could have scheduled an appointment for the same time. ARRIVAL TIME: Please arrive for your appointment 5 minutes before your scheduled appointment time. This allows for extra time to attend to your paperwork etc. Arriving early will not guarantee your service will start before your scheduled appointment time. LATE ARRIVALS: We understand that sometimes things happen outside of your control to make you late for your appointment. We will do everything we can to accommodate you, but unfortunately it will limit the time allocated for your treatment or we may need to reschedule your appointment. If we have to reschedule your appointment, you will be responsible for 50% of the value of the original service(s). Please let us know as soon as possible if you are running late so we can best accommodate everyone. Thank you for viewing and supporting our policies criteria.

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