New Customer Registration Form

Client Intake & Health History

Before you begin, take a photo of Government Issued ID/Drivers License on your phone. You will be required to upload a picture in this document, which can be easily done from your cell phone. If you are unable to complete this, please have proper ID when arriving for your appointment. (*It will be much easier and save time if you can complete this here)
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Date of Birth*

MêsDiaAno
ex. 2-18-1960
What is the best way to contact you?*

PhoneTextEmailAll of the above
How did you hear about us?*
Client History
Do you currently have any permanent cosmetics or tattoos on the area being treated?*

NoYES, please list below
Clearly indicate ALL permanent cosmetic procedures below;
What procedure(s) are you interested in? (check all that apply)*

MicrobladingMicropigmentation/HairStrokesPowdered BrowsOmbre' BrowsMicroshadingLip BlushingFull LipsColor Correction
Describe your skin:*

DryNormalVery OilyCombinationOilyI have no idea!
Have you ever had an allergic reaction to any of the following? (check all that apply)*

Benzyl AlcoholDermacaineGlycerinLanolinLecithinMetalsTattoo PigmentsVaseline or Petroleum ProductsCarbopolEphinephrineHair DyesLatexLidocainePropylene GlycolTetracaineVitamin E AcetateNoneOther
Are you allergic to anything?*

NoYes, please list below
Please list ALL allergies below;
Do you exercise regularly?*

NoYes, 1-2 times per weekYes, sometimesYes, 3+ times per week
Ethnic background; please include all nationalities. Your ethnic background will provide important insight and information relative to your skin tone, and are critical when choosing pigment color(s) and determining other important factors related to your procedure. Please be as detailed as possible. (check all that apply)*

African AmericanCaucasionMiddle EasternNative AmericanAsianHispanic/LatinMulti-RacialPacific IslanderOther
Have you EVER had any of the following health conditions? (check all that apply)*

Active InfectionAlopeciaAsthmaCancerDiabetesEpilepsyGlaucomaHerpesHIV/AIDSHysterectomyImmune DisordersLupusMigrainesSeizure DisordersSpinal InjuryThyroid ConditionVaricose VeinsAlcoholism &/or Drug AddictionArthritisBlood ClotsCold SoresEczemaFever BlistersHeart ProblemsHigh Blood PressureHormone ImbalanceInsomniaKeloid ScarringMetal ImplantsPhlebitisSkin Disease or History of MRSASystemic DiseaseTricotillomaniaNone of the above
Medications; please list ALL prescription & over the counter medications. Certain medications may cause issues with permanent cosmetic makeup.
List all Vitamins & Herbs you take daily, certain ones may cause issues with permanent cosmetic makeup.
Have you had any of the following conditions or treatments? (check all that apply)*

BotoxBrow/Lash TintiDifficulty numbing at the DentistEasy BruisingFacialSpray TanBrow/Lash LiftChemical PeelEasy BleedingFace LiftFillersTanningNone of the above
Are you pregnant or nursing?*

NoYes
Do you currently use any of the following?*

AccutaneAHAGlycolic AcidRetinolAdapaleneDifferinRenovaRoAccutaneNone of the above
Do you currently have any rashes, windburn, sensitivities, or other issues on the area being treated?*

NoYes
Does your skin form Hyper-pigmentaton (darkening of the skin), Hypo-pigmentation (lightening of the skin) or marks after physical trauma?*

NoHypo-pigmentationHyper-pigmentation
* Smoking generally reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your procedure.
Consent & Release Agreement
Date*

MonthDayYear
Date
Signature*

Clear
Photography Release Consent
This form is designed to give information needed to make an informed choice of whether or not to undergo Eyebrows; Microblading or Microshading, Eyeliner, Lip Blushing, Areola Restoration, Scar Camouflage, Color Correction, Removal or any other semi-permanent cosmetic makeup application.

If you have any questions, please don’t hesitate to ask. Although Permanent makeup is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure. Therefore, there are no refunds under any circumstances.

Please Note: Permanent Cosmetic Makeup is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent, it is considered a permanent marking.

All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after each use. Cross contamination guidelines are strictly adhered to. If at any point the area treated becomes red, itchy, oozing or overly inflammed these are possible signs of infection, you must contact a doctor or go to the nearest medical facility immediatly.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is normal and advised to expect a required touch-up after healing is completed, and perhaps you may need an additional touch-up at an additional cost.

Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade approximately 35%, soften and look more natural. The pigment is semi-permanent and will fade over time.

An color boost is suggested every 12-36 months, depending on the procedure, however everyones skin reacts differently so a touch-up may be needed sooner.
Our insurance company requires "Before and "After" photos/videos be taken and kept on file.Fabi Permanent Cosmetic Studio would like your permission to use these photos/video for advertising. For example, in portfolios, online and in print ads, etc. Your consent and permission is necessary. Please check the appropriate box below.*

I grant permissionI do not grant permission
Date*

MonthDayYear
Date
Signature*

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Possible Risks, Hazards or Complications
• Pain: There can be some pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others.

• Infection: Infection is very unusual but can happen, if at any point the area treated becomes tender to the touch, red, oozy, etc., you should contact a health professional immediately. The areas treated must be kept clean, and only freshly cleaned/sanitized hands should touch the areas. See “After Care” sheet for instructions on care.

• Uneven Pigmentation: This can result from poor healing, infection, bleeding, 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 adjustments may be needed during the follow-up session to correct any unevenness.

• Excessive Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling, and swelling or bruising typically disappears in 1-3 days. Many clients do not bruise or swell at all.

• Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform us immediately.

• 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 machine. You must inform your MRI Technician of any tattoos or permanent cosmetics.

• Allergic Reaction: Although an allergy is unusual, there is always a possibility of an unknown allergy to the pigments and materials used during your procedure.

The alternative to these possibilities is to use traditional cosmetic and NOT undergo the Semi-Permanent Eyebrow, Lip Blushing, Eyeliner, Or any other semi permanent makeup procedure.
Date*

MonthDayYear
Date
Signature*

Clear
Consent & Release Agreement

By checking the "I Understand" box, you are initialing that you fully understand that you are entering a legally binding contract
Please read the following statements carefully and initial to acknowledge your understanding of each.
Although rare, the pigment can migrate under the skin*

I understand
I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.*

I understand
I understand that tanning beds, pools, saunas and some skin care products and medications can affect my permanent makeup.*

I understand
I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.*

I understand
The micropigmentation procedure may be slightly uncomfortable*

I understand
Pigment can appear 35-40% darker than desired result immediately following and for a few days after procedure.*

I understand
Although rare, there may be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the procedure. Seek immediate medical attention in the event of a suspected reaction*

I understand
I understand that exercising during the healing process can alter the desired effects of my procedure. I cannot hold the Artist responsible for poor retention. If at any point my Artist finds evidence that any of these rules have not been followed, the Artist has the right to release me as a client or to charge me for an additional touch-up fee of $150.00*

I understand
Permanent Makeup is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure, therefore there are no refunds under any circumstances. And additional touch-ups may be needed.*

I understand
I accept full responsibility and will explain to the Artist my desire for specific pigment colors, shape, and position during consultation and/or prior to any procedure.*

I understand
I understand fully what is included in my package, I also understand that touch-ups are necessary.*

I understand
I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond the Artists' control, and I will need to maintain the color with future applications. It is highly recommended to schedule the touch-up session within 6-8 weeks of the initial procedure to obtain maximum results.*

I understand
I acknowledge that the proposed procedure(s) involve risks inherent to the procedure, and have the possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention, hyper-pigmentation, scarring, bleeding, & nerve damage.*

I understand
Allergic reactions to anesthetic can occur, seek immediate medical attention in the event of a suspected reaction.*

I understand
It is illegal to apply permanent cosmetic makeup to women who are pregnant or nursing.*

I understand
It is illegal to apply permanent cosmetics to anyone under the age of 18 without parental consent. The Artist reserves the right to make the final determination to accept the client.*

I understand
Infections can occur if after care instructions are not followed correctly.*

I understand
Not following Pre-Care & Aftercare instructions completely may result in poor retention, uneven healing, scarring and a negative outcome, etc.*

I understand
If the Artist deems that I have not followed the Pre-Care & Aftercare adequately, this can result in dismissal as a client with NO REFUNDS, or I will be charged the regular price for a touch-up.*

I understand
I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill in any additional pigment, and MUST be completed within the time frame given to me by the Artist.*

I understand
There may be swelling, redness or minor discomfort following the procedure.*

understand
Scarring is rare but may occur.*

I understand
Care & Maintenance
The Client hereby releases the Artist, its Principals, Agents, and Employees, from any and all liability, actions, causes of action, claims, loss, demands, damages, or injuries, including legal costs, loss of profit, or other special or consequential damages, howsoever arising. That the Client now has or hereinafter may have, against the Artist by reason of or in any way related to the Procedure. The Client agrees to indemnify and hold harmless the Artist, its Principals, Agents, and Employees from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, resulting from, or in any way connected to the Procedure.*

I understand
I agree to follow the aftercare and maintenance instructions provided by the Artist for the care of the area following my procedure, and that if any follow-up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that failure to follow aftercare instructions may result in permanent damage to my skin, scarring and may prevent the pigment from settling. I agree to keep the procedure area clean and to follow all aftercare instructions. This includes avoiding exercising, tanning, and skincare products as outlined.*

I understand
No Known Medical Conditions & Informed Consent
I have read and completed the Procedure Intake Form in its entirety and have answered all questions truthfully. I acknowledge that I have been advised of the potential harmful or negative side effects (such as keloid scarring, or infection) that the Procedure may cause to those who have specific medical or skin conditions. I understand that in rare cases some clients may be allergic or have hypersensitivity to some of the products used during the Procedure. I understand that allergies to pigments may develop at any time after the Procedure, while the pigment is implanted in my skin. I further state that I have no known medical condition that might be aggravated by the Procedure or any medical condition that would prevent me from complying with or following the Artist’s instructions and these warnings.*

I understand
Spot & Patch Testing
I understand, that should I have any concerns about any possible reaction to the chemicals and products used, I may arrange at my own discretion to book an advance spot test where topical anesthetics and pigment will be applied to my skin externally, 24-48 hours prior to the time in which I am scheduled for the Procedure. I also understand that spot testing does not guarantee that no future sensitivity or reactions will develop. I agree that scheduling a spot test shall be my own responsibility and at my sole discretion, and have absolutely no bearing on the contents or signing of this Agreement or any clauses contained herein.*

I Understand
Right to Refuse Service
Though it is extremely rare, we reserve the right to refuse treatment for the following reasons. The full service fee will still apply, as we are not able to schedule this time with another client; • Undisclosed skin condition (including sunburn/suntan) • Using Retin-A & Skin care products • Under the influence of drugs or alcohol • Any behavior which, in the opinion of the Artist may compromise the Artist’s ability to work safely and comfortably toward the desired results, or may disrupt other clients. • Being rude, nasty, calling, texting repeatedly or cursing at the Artist, and or any employee of Fabi Permanent Cosmetic Studio. This does not happen very often, however, if this does happen the Artist reserves the right to immediately dismiss the client. All efforts will be made to rectify the situation and make every client completely satisfied, however the Artist reserves the right to make the decision regarding each situation. In addition, the Artist reserves the right to refuse treatment at their sole discretion and there are no refunds under any circumstances.*

I understand
Cancellation Policy
I understand that each appointment time is reserved specifically for the Client. A cancellation, late or missed appointment leaves a gap in the Artist's schedule that could have been filled by another client. The Artist requires a 48 hour notice from the scheduled appointment time for any cancellations or changes to your appointment. Clients that provide less than 48 hours notice from their scheduled appointment time will forfeit their booking fee and be charged a fee of $75.00 to reschedule. Any client that reschedules less than 48 hours from their scheduled appointment time, or misses their appointment by being more than 15 minutes late, or is a no show will be subject to a charge of 50% of the cost of the procedure as booked. If the Client arrives late for their appointment and both parties agree to continue, no additional time will be added to the appointment. However, if it interferes with the next scheduled client's appointment time the procedure will be stopped at the scheduled end-time of the appointment, regardless as to whether or not the desired outcome is achieved in the remaining amount of time. The client will be charged in full for the service time as booked, and may be required to schedule another appointment for an additional fee to complete their procedure in its entirety.*

I understand
Touch-Up Appointments - Cancellation & Rescheduling Policy
I understand that if I reschedule less than 48 hours from my scheduled appointment time, or I am a no show, the touch-up session is forfeited as touch-up session are complimentary. In order to re-book the fee will range from the $75.00 booking fee to the price of an Annual Touch-up/Color Boost. This price will be determined by Artist*

I understand
I fully understand that it is my responsibility as the client to schedule my touch-up and/or follow-up appointment, no later than 8 weeks from the day of my initial procedure/appointment.*

I understand
Please Note: The Artist works during normal business hours conducting procedures, and I am fully aware that on occasions the Artist may not be able to respond during this time. However, every effort will be made to return calls, texts and messages within the same business day.*

I understand
I understand that 24 hours is at times required for responses. The majority of the time the Artist will respond sooner, however, please allow at least 24 hours for your response. If you still have not heard from the Artist please feel free to call, text or message again.*

I understand
Immediate availability is very rare, I understand that it is up to me to schedule my sessions accordingly, and if an appointment is needed sooner then available, I understand that there is a SKIP THE LINE fee of $150.00 to accommodate clients, which may require hours outside our normal business hours.*

I understand
I understand that ALL services are By Appointment Only. Showing up to the studio unannounced and without the Artists' permission can lead to the dismissal as a client. This is a very intimate procedure and if you show up unannounced or because you are upset, it will cause anxiety to not only the client in the chair but the Artist as well, and this is unfair to all parties involved.*

I understand
I understand that Emergency Removal is available at a Fee of $250.00. This must be done within the first 72 hours of the initial procedure. Client hereby understands that if they ask for an emergency removal, this now fulfills the contractual duties, and there will be no more future sessions permitted.*

I understand
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or poor retention on the procedure area. I am aware that it is my responsibility to inform the Artist of my current medical or health conditions and to update this history. This is an elective procedure, with no guarantee's and I release Fabi Permanent Cosmetic Studio and its associated from liability and assume full responsibility thereof.*

I understand
To cancel or reschedule an appointment; please contact Fabi Permanent Cosmetic Studio at (804) 4426130, at least 48 hours prior to your scheduled appointment time. Any client that reschedules less than 48 hours from their scheduled appointment time, or misses their appointment by being more than 15 minutes late, or is a no show will be subject to a charge of 50% of the cost of the procedure as booked. In addition, a $75.00 booking fee will be required to schedule a new appointment.*

I understand
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved with this procedure(s). I have had the opportunity to ask questions, and agree that all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize Fabiana Moura, and Fabi Permanent Cosmetic Studio as my Permanent Cosmetic/Makeup Technician to perform said procedures on my body as agreed.*

I understand
Upload an Image of your Government issued ID or License
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Client Intake & Health History

Client History

Consent & Release Agreement

Photography Release Consent

Possible Risks, Hazards or Complications

Consent & Release Agreement

Care & Maintenance

No Known Medical Conditions & Informed Consent

Spot & Patch Testing

Right to Refuse Service

Cancellation Policy

Touch-Up Appointments - Cancellation & Rescheduling Policy