Scar / Stretch Mark Camouflage Intake

Malorie Harris LLC

223 Creekside Office Drive Wentzville, MO 63385

314-265-7542
Scar / Stretch mark Camouflage Intake
Name
Date

MonthDayYear
Date
DOB
AGE
Address
Phone
Occupation
Email
example@example.com
Medical Background: Check all that apply (past and present)

Pregnant/BreastfeedingBleeding Disorder, HemophiliaEpilepsyKeloid/Hypertrophic DiseaseCancerCardiac/Vascular ProblemsRecent Surgical IncisionHormone Replacement TherapyDiabetesHIV/AIDS, HepatitisSmoking/Tobacco UsePsoriasis, Eczema, Rosacea, DermatitisTransdermal Drug Delivery SystemActive InfectionThyroid Disorders/DiseaseHives, Herpes, ShinglesAnticoagulants (Blood Thinners)Scleroderma, Rheumatoid Arthritis, LupusBotox/Dermal Fillers/Chemical PeelAllergy to Numbing Agents or AnestheticsPacemaker/Othe Electronic Device ImplantRaised Lesions, MolesHeart/Kidney/Liver DiseasePlastic/Bone Cement/ Metal Implants
Other Medical Conditions
Allergies
Current Medications
Please check if you are using any of the following

AccutaneRetin-APhotosensitizing MedicationsHydroquinoneAlpha Hydroxy AcidsOther Topicals:
By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes to the information listed on all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward Malorie Harris LLC for any injury or damages incurred due to my misrepresentation of my health history.
Signature

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Date

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Date
Scar + Stretchmark Camouflage Consent
Name
AGE
DOB
1.

I agree that am over the age of 18. I am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing and desire to receive the scar/stretch mark camouflage procedure.
2.

I understand that needles are used for the scar and stretchmark camouflage procedure to inject color pigments into the upper layers of the skin over the scar and/or stretchmark.
3.

I have been informed of the nature, risks, and possible complications and consequences of the scar and stretchmark camouflage procedure. I understand the procedure may have known or unknown complications including but not limited to: infection, allergic reaction, scarring, keloiding, inconsistent color, hyperpigmentation, hypopigmentation and the spreading or fading of pigments used.
4.

I understand that there is a possibility of undesirable results and understand that each persons outcome is different and there are no guarantees to my results. I agree that Malorie Harris LLC has not made any claims of guarantee to me.
5.

I understand the actual color of the pigment may be modified slightly because scar tissue accepts pigments differently than normal tissue.
6.

I understand that camouflaging scars and stretch marks does not yield instant results, but takes time and patience for the natural healing cycle of the skin to occur. I understand it may require multiple appointments spaced 6 weeks apart.
7.

I understand a patch test may result in an allergic reaction.
8.

I request the scar and stretchmark camouflage procedure(s) and accept the permanence of the procedure as well as the possible complications and consequences of the procedure. I understand that If I am prone to hyperpigmentation or keloids, I am not a candidate for this procedure.
9.

I understand that if I have any skin treatments including but not limited to laser hair removal, plastic surgery or other cosmetic procedures, it may result in adverse changes to my permanent cosmetics and may not be correctable.
10.

I understand that I should keep sun exposure to a minimum once my scar and/or stretchmarks have been camouflaged.
11.

I have received pre- and post care instructions (located at the bottom of this page) and will strictly adhere to such instructions. I understand that my failure to properly follow pre and post care instructions may compromise my procedure.
By signing below, you agree to the following:

I consent to allow Malorie Harris LLC to consult with and evaluate me in order to determine if I am a good candidate for the scar and stretchmark camouflage procedure. I understand that photographs may be taken and kept in my file and used for portfolio purposes. I agree that these forms have been completed truthfully and to the best of my knowledge and abilities. I understand the contraindications and possible side effects of the scar and stretchmark procedure. Furthermore, l agree to waive all liabilities toward Malorie Harris LLC for any injury or damages incurred due to my misrepresentation of my health history or failure to follow pre- or post care instructions.
Signature

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Date

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Scar/Stretch Mark Camouflage Pre/Post Care
Before the procedure

1. Avoid antibiotic therapy at least 4 weeks prior to appointment. If unavoidable, please contact your practitioner for further guidance as antibiotics result in higher candida (yeast) count and infection may result.

2. Avoid alcohol and blood thinning medications at least 24 hours prior to procedure.

3. Avoid caffeine 12 hours prior to procedure.

4. Drink plenty of water to hydrate.

5. Do not wear serums, toners, creams or other products the morning of your procedure.

6. Do not tan skin with sunless tanners, self-tanners, spray tan, tanning booths, or sun-tan for at least 4 weeks prior to the procedure. If the surrounding skin is tanned, the chosen pigments for the scar or stretchmark camouflage may end up being darker than your natural skin tone.

7. Gently exfoliate the area to be treated the day before the procedure to slough off dead skin cells.
After the procedure
Redness and swelling is normal and expected for 3 to 5 days post procedure.

1. Avoid getting the treated area too wet from showering and avoid submerging the area including swimming in a pool, ocean, lake, hot tub or any water source for 7 days.

2. Avoid sweating for a minimum of 7 days - no gym, yoga, exercise.

3. Clean the area with a small amount of water on a cotton pad before you go to bed and each morning after the procedure followed by a thin layer of A&D or Aquaphor ointment. Aquaphor can be applied 3x a day.

4. Do not scratch, rub or pick at the treated area. It will be slightly itchy.

5. Do not use other ointments, creams, or antibiotics until fully healed.

6. After the first 2 weeks always AVOID direct sun exposure and always use SPF 30+.

7. Avoid using harsh soaps, creams, fragrances, and lotions. After day 7, it is best to moisturize every day with LaRoche- Posay Cicaplast Balm B5. It can be found on Amazon.
Should be Empty:

Scar / Stretch mark Camouflage Intake

Scar + Stretchmark Camouflage Consent

Scar/Stretch Mark Camouflage Pre/Post Care

After the procedure