New Client Intake Form, Informed Consent, Photo Release

CLIENT INFORMATION & HISTORY
Client Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
YesNo
Who may we thank for referring you?
Permanent BrowsLash EnhancementPermanent EyelinerPermanent Lip BlushUltra Realistic Areola TattooScar CamouflageOther
CLIENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOBILE NUMBER (That can receive texts and follow up reminders)*
Format: (000) 000-0000.
OTHER PREFERRED PHONE NUMBER
Format: (000) 000-0000.
E-mail*
example@example.com
Yes
Retin AGlycolic Acid or ANY Exfoliating Products/EnzymesChemical PeelsVitamin C Facial SerumLaser Treatments (IPL, etc...)NONEOther
Are you planning cosmetic surgery? If so, When?
YesNo
Primary Physician Name*

First NameLast Name
Primary Physician Address

Street Address

CityState / Province

Postal / Zip Code
Primary Physician Phone Number*
Format: (000) 000-0000.
YesNo
If yes, please specify why you are under the care of a physician.
YesNo
Pregnant or NursingUndergoing Chemotherapy and/or Radiation treatments (prophylactic chemotherapy is generally safe to proceed)Undergoing active dermatologic disorders to the area being treated, i.e. Rosacea, eczema, psoriasisNONE OF THE ABOVE
Mitral Valve ProlapseAutoimmune DisorderProblems with HealingKeloidsHemophilia or Clotting DisorderPre Existing Nerve DamageTrichotillomania (Pulling of hair, brows, or lashes)Alopecia Totalis or AreataProne to Eye InfectionsFainting SpellsEye TraumaNONEOther
YESNO
IF YOU HAVE HAD HEPATITUS OR HEPATITUS TEST, WHAT TYPE & WHEN?
SeizuresHeart Valves, stents, pacemakers, Rheumatic FeverOrgan TransplantJoint ReplacementInsulin Dependent DiabetesFever Blister History (Required for Lip Blush only)NONE OF THE ABOVE APPLY TO ME
Glaucoma or Grave's Disease (Required for Eyeliner only)Glaucoma Eye Drops (Required for Eyeliner only)SeizuresNONE OF THE ABOVE APPLY TO ME
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

LIST MEDICATIONS YOU ARE PRESENTLY TAKING

Rows	NAME OF DRUG	WHY IS IT PRESCRIBED?	MG OR MCG
1
2
3

INFORMED CONSENT
I have received, reviewed and understand
I understand & accept
I accept
I accept
I accept
I accept
I understand and agree
I understand and accept
I understand and accept
I understand and accept
I understand, agree, and accept
I agree
I agree
I am aware and agree
I accept and understand
Client signature required. Client agrees that all intake forms & client information filled out by the client is true and correct*

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Aftercare for all Cosmetic PMU
HOW TO CARE:

Day 1: (Day of Service) No moisture to the area, except gentle patting. With a damp, clean, cotton pad every 10 minutes for the first two hrs after the service. The purpose is to remove clear lympathic fluid. Shower as usual; However, do not place your face directly into the shower.

*Refer to all information regarding "what to avoid." Sleeping propped up and on your back is ideal for the first few days of healing. Change pillowcase nightly. No exfoliating soaps.

Day 2: Gently wash the pigmented area with mild soap & water using fingertips 1-2 times per day. The area may feel dry or chapped but refrain from moisturizing the area at all.

Day 3-6: Repeat washing. You can now apply grapeseed oil 2x per day. Peeling or sloughing may occur. DO NOT PICK!

WHAT TO EXPECT:

Day of your appointment: Slight swelling or soreness. The area may "weep" a clear lymphatic fluid. This is normal. Fairer complexions may become more pink or red immediately after your appointment.

The color may be 30-40% darker, and appear to have a warmer undertone than when healed. The color can darken the first few days due to oxidation.

The pigment will possibly be the lightest color between day 4-7. The color will then "bloom" over the next 28 days.

WHAT TO NOTICE: If a red ring appears around the pigmented area seek medical attention.

For Eyeliner only: Your eyeballs should not become more red. You must seek medical attention immediately if you see signs of bloodshot eyes or puss in the corners of your eyes. This may be an infection requiring a physician and prescribed medication.
WHAT TO AVOID:

Avoid exfoliating skin products and enzymes. For example, Retin-A, vitamin C serums, glycolic acid, exfoliating facial soaps and medical grade exfoliating enzymes/lotions/facials.

No exfoliating skin treatments. For example, asers, chemical peels, IPL or facials between your initial appointment and your touch up. Please discontinue for at least 3-4 weeks before & after your appointment.

Avoid placing your face directly into the shower for the first week.

Avoid direct sunlight while healing.

Avoid any form of salt. For example, salt water pools, salty gulf water, sweating. For permanent lip blush only, you will want to avoid salty foods.

Avoid dirt. For example, gardening.

Avoid high bacteria scenarios. For example, saunas, steam rooms, makeup products or touching the pigmented area with your hands.

Never use topical antibiotics For example, neosporin.

For permanent lip blush only: Avoid salty foods, extended wear lipsticks & plumping gloss while healing. Avoid teeth bleaching for at least 3 weeks. For day 1 & 2, avoid licking your lips, getting your lips wet and heavy kissing. Avoid rubbing your lips together. No picking.

For permanent eyeliner only: Avoid eye creams, latisse & lash growth products. Absolutely no lash tinting, NO lash extensions, false eyelashes for 3 weeks following your appointment. Due to bacteria you want to avoid eyeshadow, eyeliner, mascara until completely healed. Avoid rubbing your eyes.

For areola and scar camouflage only: Avoid allowing the pigmented area to be in direct contact with the air for longer than 15 minutes for the first 14 days. The area must be sealed Day 1-7, and then covered with guaze Day 7-14. See aftercare instructions below.
I understand, consent, and agree to all aftercare information and understand that healed results is dependent upon the preparation and care for PMU
Our Policies
I agree
EXPECTATIONS POLICY: Cosmetic tattooing does not fully replace wearing makeup. Permanent makeup is best when it enhances your natural features. Healed results will vary with each client and using makeup may still be needed. We have no control over the healing process, and it is very important to follow all guidelines in order to achieve the best and most lasting results. Absolutely no guarantee will be made and additional sessions may be required to obtain optimal results and charged accordingly.*

I agree
I agree
I agree
RESCHEDULING POLICY: Rescheduling within 48hrs of your appointment will forfeit your $100 deposit/scheduling fee and will require a $100 deposit to reschedule. You must email info@outlinerstudio.com (only) to let us know if you cannot make your appointment. Appointments are in high demand at Outliner Studio, and respectfully please give us time to fill your spot. Repeat rescheduling will require a non-refundable & non-transferable payment in full before rescheduling.Email: info@outlinerstudio.com (only)*

I agree
I agree
INITIAL TOUCH UP POLICY: An initial touch up may or may not be needed. The 12 week touch up is an additional $100 added to the entire cost of the procedure and are sometimes needed to perfect or make additional adjustments after the initial healing process. Everyone's skin, healing process and required touch ups vary per individual. Any appointments scheduled or rescheduled after 12 weeks is $250.To cancel your appointment email info@outlinerstudio.com *only. Any rescheduled initial touch up appointment cannot be guaranteed as they are subject to the availability of the artist’s schedule.If the touch up is completed after 12 weeks due to rescheduling, any touch up will be charged a regular touch up fee of $250.*

I agree
TOUCH UP TIME-FRAME POLICY:An initial touch up is sometimes needed after the initial appointment. The initial healed results depends on the clients preparation, aftercare, metabolism, medications or quality of the skin. The price is $100 10-14 week period after the original treatment for adjusting, adding more color, or treating any areas that may not have retained the pigment. We have no control over your healing process. In order to achieve the best results, the initial touch up is highly recommended - even if your PMU results are already beautiful and is $100. If rescheduled, this appointment cannot be guaranteed as they are subject to the availability of the artist’s schedule. If a rescheduled touch up does not return within the allotted time frame (10-14 weeks), you will be required to pay for a touch up service of $250.*

I agree
CONSULTATION POLICY:Consultations are an important step of finding the artist that is right for you! A nonrefundable and non transferable $25 scheduling fee is required in order to book a consultation. The consultation does not guarantee that the client will be able to schedule an permanent makeup appointment after the consultation. Booking depends on if the artists discretion or if the corrective procedures is workable.*

I agree
I agree
PRE APPOINTMENT INFO + CONTRAINDICATION POLICY:All clients are responsible for checking candidacy prior to any appointment. If you arrive at an appointment and can not receive treatment due to any listed contraindications, your appointment will be cancelled and your deposit will be forfeited. Please read all pre procedure information, aftercare information and policies before scheduling your appointment.*

I agree
PREVIOUS PMU + CORRECTION SERVICES + REMOVAL POLICY: If you have had previous permanent makeup and you are interested in a cover-up or correction, you must email clear photos prior to booking your appointment. We cannot guarantee results for cases such as these and we must confirm your case is workable. We do not touch up other artists work at a "touch up fee" since many times these are corrective procedures.In some scenarios where the work is too dark, dense, discolored, or extensive tattoo removal may be required before we begin the coverup re-work. Previously tattooed areas and cover-ups will almost always require additional appointments and cost. If you come to your appointment with previously microbladed or tattooed eyebrows from another artist without informing Outliner Studio, your appointment will be cancelled and you will forfeit your deposit.*

I agree
GIFT CERTIFICATE POLICY: Gift certificates are purchased in full. They are a non-refundable and non-transferable. All sales final, can not be combined with other offers.The gift certificate must be used by the person for whom they were purchased and they must be used for the purchased service. The purchaser and client are responsible for going over all pre appointment information provided by this website.Gift certificates expire 12 months from the purchase date and must be brought to the appointment.*

I agree
Signature*

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CLIENT INFORMATION & HISTORY

INFORMED CONSENT

Aftercare for all Cosmetic PMU

Our Policies