PERMANENT COSMETIC INTAKE FORM

PERMANENT COSMETIC INTAKE FORM
Name *

First NameLast Name
Email * *
example@example.com
Phone Number * *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth * *
How did you hear about Haven Studio Co?
List any medications you have taken in the last six months: *
Have you received Chemotherapy or radiation in the last year? *

YESNO
Are you currently pregnant or breastfeeding? *

YESNO
Have you ever had an allergic reaction to any of the following: *

LatexLanolinVaselineLidocaineMetalsGlycerinNo allergies to any of the above
Any other allergies you have that were not listed?
Are you currently taking medication that thins the blood? Ibuprofen, Aspirin, Fish oil, Vitamin D or E, Coumadin etc.*

YESNO
If yes, please explain:
Are you currently under the care of a physician? *

YESNO
If yes, please explain:
Have you ever had one of the following: *

HairlossTrichotillomaniaHemophiliaLiver DiseaseThyroid DisturbancesAnemiaEpilepsyHIVAlopeciaCancerSensitivity With CosmeticsArtificial Heart ValveFainting Spells or DizzinessTumors, Growths, CystsHealing ProblemsProlonged BleedingHepatitisLow Blood PressureHigh Blood PressureUse Retinol, Retin-A or AccutaneBotox, Filler or InjectionsDiabetesDo You Scar Easily?Hypertrophic or Keloid ScarsDo You Bruise or Bleed Easily?Skin Issues/Eczema/RosaceaEye SurgeryLip/Mouth Surgery/Filler/InjectionsGlaucomaCold Sores/History Of Cold SoresRecent Dental Work?Use Eyelash Growth SerumsFacial/Chemical Peel Recently?Do You Smoke or Vape?None Of The Above
If yes, please explain
Have you had Alcohol or Caffeine within the last 24 hours? *

YESNO
If yes, how much?
What would you like to improve about your eyebrows, lips or eyes? Consider shape, color, density, thickness...
I fully understand the information provided above and confirm that all information provided by me is correct and truthful. *

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USE OF TOPICAL ANESTHETIC

- Allergic reaction can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.

- Numbess: We cannot accept responsibility if the area to be treated does not respond to the anesthetic. Each individual is different according to skin type. Some clients report the area to be completely numb, while others may experience some discomfort.
I have read and fully understand the above information provided and any risks involved with the use of topical anesthetic and I therefore consent to the use of the anesthetic for the procedure. I agree to follow pre-procedure and post-procedure advice closely. * *

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PHOTO AND/OR VIDEO CONSENT

This authorization grants permission to use your image (still or moving) and/or your spoken words in perpetuity for educational purposes. By signing this document, you agree:

1. To allow the recording of your image and voice (e.g. photographs, audio, or video).

2. Distribute your image or recording in any medium, be it print or electronic form, which may include the internet.

3. To grant permission to other entities to reproduce the images or recordings for educational purposes.

4. That there is no reimbursement for the right to take, or to use your photograph or video or recording.
Do you give Haven Studio Co consent to use your video and/or photos? *

YESYES, only if my face is not shownNO
Signature * *

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By signing below I am verifying that I understand and approve of the following:
I understand that permanent cosmetics may last 9 months to 48 months depending on how my skin reacts to the procedure and how I care for my skin. There may be fading and/or discoloration. The results may not be what I expected to receive. *

I understand
I understand one $150 touch-up is required within 6-8 weeks of my initial appointment. I must schedule the touch-up for 6 to 8 weeks after my initial treatment. Touch-ups are important for perfecting any areas that may shrink in size or fade in color. Touch-ups also help with longevity of results. Cancellations or reschedules are required 72 hours prior to your appointment. *

I understand
I understand there is no warranty or guarantee made to me as a result of this procedure and the final results cannot be guaranteed. There are no refunds for this procedure, as results will vary and individual results are not guaranteed. *

I understand
I understand clients with oily skin or sensitive skin (bleeding/lymph) may require additional touchups or additional shading to promote better pigment retention. *

I understand
FOR LIPS: I understand clients with darker skin tones who want lip treatment may have reversed results, such as hypopigmentation or hyperpigmentation. The needle abrades the skin therefore this process may trigger the body to under produce or over produce new skin cells causing hyper or hypo-pigmentation. As a result of this procedure and the final results cannot be guaranteed. *

I understand
FOR LIPS: I understand clients with a history of cold sores will be advised to get a anti-viral Rx from physician to take before and after lip treatment. Lip treatment abrades/irritates lip membrane, which may cause a cold sore to occur if a client has a history of cold sores. Rarely does a cold sore occur to a client who does not have a history of cold sores. As a result of this procedure and the final results cannot be guaranteed. There are no refunds for this procedure, as results will vary and individual results are not guaranteed. *

I understand
FOR EYES: I understand clients who have skin tags or veins surrounding eyelid will not have ink placed/or be worked on in these areas, for this can cause skin outbreaks or ink migration. Clients who wear contact lenses will need to remove contact lenses before treatment and not reapply contact lenses after service for 2-3 days. If client has an eye condition please inform studio right away. It is rare, but client's with allergies or prior eye conditions may develop minor eye irritation or eye infection. Eyewash and eyedrops are applied during and after treatment. As a result of this procedure and the final results cannot be guaranteed. There are no refunds for this procedure, as results will vary and individual results are not guaranteed. *

I understand
I understand upon proceeding with the treatment, I consent to the pre-draw shape that my artist created. I understand that this is a guideline for the shape and size of my design and it may vary slightly once the procedure is done. *

I understand
I understand there may be risks and hazard related to performing this procedure. There is a possibility of bleeding, swelling, redness and allergic reactions to pigments or infection (infections are rare, but can occur if client does not follow aftercare properly). Haven Studio prides themselves on the highest quality equipment and disposable tools to prevent infections. *

I understand
I understand that there may be discomfort and pain during this procedure. *

I understand
I understand permanent makeup can/will fade over time. Though semi-permanent pigment may last permanently and may not fade. *

I understand
I understand surgical procedures may be required to remove pigment from skin. These procedures may cause scarring and permanent damage to the skin. *

I understand
I understand the final result cannot be determined until the area is completely healed at 6 to 8 weeks. *

I understand
I understand that permanent and semi-permanent makeup procedures cannot be guaranteed and results cannot be predicted, as there are many variables that contribute to the final result, such as aftercare, skin type, lifestyle, etc. *

I understand
I understand that I will receive detailed post care instructions and will follow them to ensure results of my procedure are satisfactory. *

I understand
I am NOT pregnant or breastfeeding. *

YES
I am NOT a minor (under 18 years old). *

YES
I am NOT under the influence of drugs and/or alcohol or any other mind altering substance. *

YES
I fully understand the procedure and give permission/consent to my technician to perform the service and all procedure and steps involved.*

I consent
I release Haven Studio Co and it's representatives and licensed technicians of all claims and injury, seen or unseen that may occur as a result of this procedure. *

I agree
I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I will need to return for a touch-up procedure. The results of the procedure can be effected by the following: medication, skin characteristics (dry, oily, sun-damaged, wrinkles, large pores, thick or thin skin), personal pH balance of your skin, alcohol intake and smoking, post procedure and pre procedure care. Upon completion of the procedure, there might be swelling and redness of skin, which will subside within 1-4 days. You may resume normal activities following procedure; however, using cosmetics, excessive perspiration and exposure to the sun should be avoided or limited until the skin has fully healed. * *

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COVID-19 Precaution Release
Have you been exposed to COVID-19 that you know of? *

YESNO
Do you have any COVID-19 symptoms such as coughing, sneezing, fever, or sore throat? *

YESNO
Have you traveled out of the US in the last two months? *

YESNO
I fully understand the information provided above and confirm that all information provided by me is correct and truthful. * *

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Date*

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