Jealousy Studios

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Appointment Date

Date

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Name

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Date of Birth

Date

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Today's Date

Date

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Street

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City

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State

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Zip

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Home Phone

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Business Phone

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Cell Phone

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May we contact you at these numbers?

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Email Address

example@example.com

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Referred by

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Ethnic Background (include all nationalities)

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Emergency Contact

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Phone Number

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PROCEDURE(S) DESIRED: Please write y or N to all of the following that apply. If you have any questions feel free to type them here.

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Powder brow, Microblade, Upper or Lower Eyeliner, Lip, Beauty Mark, Freckles, Hairline or Scalp, Scar, Areola or Bodyart

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Non Surgical Wrinkle or Anti-aging Treatments

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Botox or Fillers (done by our P.A.on Site)

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Weight Loss Consultation

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The following confidential medical information will be property of Jealousy Micro-pigmentation Studios (JMP Ventures LLC) This is required for the benefit and safety of the client in Obtaining any and all procedures performed by Jealousy Studios. Please read and fill out the information carefully. We hope your experience will be a pleasant and we are honored to serve you.

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ALLERGIES: Write Y or N to the following. Describe in the box below if you have ever had an allergic reaction to any of the following and described what happened below.

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Neomycin Ointment, Bacitracin Ointment or Polymyxin B Ointment, Latex Rubber Lanolin, PABA, Tattoo or ink pigment, Metals, Novocain, Lidocaine, Benzocaine, Tetracaine, Foods, Other (if yes please list and write reactions)

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EYES/EYEBROWS: Answer yes or no to all of the following that apply. Please list any other issues below.

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Pull out lashes/eyebrow compulsively (Trichotillomania), Blurred Vision, Alopecia Universalishh (total), lasic, glaucoma or other eye surgery, thyroid eye, dry eye, contacts or other eye disorders

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have you had or plan to have botox? If so when?

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LIPS: Write Y or N for all of the following that apply. Explain your answer if nessicary and feel free to ask questions here.

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*Cold sores/fever blisters/herpes?(type yes even if only one time) If yes, an antiviral prescription is required prior to any lip procedure to prevent them. 3 days before & 3 days after the Lip Procedure. *Lip injections? If YES was it done within two weeks of desired procedure date? * Tooth Bleaching or Whitening? If yes when? *Scarring around mouth area? If yes when did this happen?

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SKIN: if Yes please list with explanation or N to all of the following that apply. Explain any further information that is needed. Feel free to ask questions here.

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*Have you tanned or plan on being in direct sun in the next 2 or last 2 weeks? * Do you Currently use Retin A or any prescription for your skin? Any other tattoos Location if so what is the age of the tattoo, if so any problems with tattoo? * Do you have healing problems or bruise easily? * Do you have any skin Disorders ie: Eczema, psoriasis, rashes?* This field is required.

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* Any Chemical Peels in the last 6 weeks? If so what type of peel? * Do you have any Scars, Dark Spots or Wrinkles you would like treated?

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GENERAL MEDICAL: If Yes to any of these conditions please list, if No leave blank. If you have any of these conditions it does not nessicarily mean you cannot get this service, we just need to be aware prior to working with you.)

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* Diabetes? If so please contact your Artist prior to your appointment to receive a dr note for clearance. * High Blood Pressure? * Heart Palpitations? * Mitral valve prolapse? * Currently on blood thinners or anticoagulants such as Coumadin, aspirin, ibuprofin, vit E, Fish Oil, excessive Caffeine consumption or alcohol? (Please speak to your practitioner if you are on any of these items or have questions.) * Any blood disorders such as hemophilia? * Autoimmune disease * Seizure Disorder *Any mental impairment, Bi-Polar disorder or Clinical Depression?* This field is required.

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For eyeliner procedures only: Are you using any lash growth products? If so, Please discontinue use of the product for at least 2 weeks Prior to your procedure and reschedule if nessicary.

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*Are you annemic? *Do you have a condition such as Hepatitis, HIV or undergoing treatment such as chemotherapy that could affect healing? Are you currently undergoing or have you undergone Chemotherapy in the past 6 months?

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Do you wear contact lenses? if yes and you are undergoing an eyeliner procedure they must be removed before procedure and remain out for a minium of 24 hours following your procedure.

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Current use of controlled substances describe:

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Please list any surgeries

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If you are planning cosmetic or other surgeries/procedures in the near future, describe

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List all medications, prescription and non prescription that you have taken in the last two weeks

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Are you pregnant or Lactating, if yes please inform your practitioner immediately.

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If you are currently under a physician's care for any condition, describe

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Physician's Name

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City

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Phone

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This history has been reviewed by the technician and my questions have been satisfactorily answered. I have also received and reviewed a copy of the Pre-Procedure Information Sheet and the After Care Sheet. I understand them and agree to follow them.

I am not Pregnant.

I am over the age of 18 and in sound mind, body, and health.

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Signature

Clear

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Date

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Informed Consent for Procedure

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE THAT YOU UNDERSTAND WHAT THEY MEAN BY INITIALING NEXT TO EACH PARAGRAPH

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1. I absolutely understand and accept that this procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed.

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2. I understand the focus is the second session to complete the original work. It is a mandatory visit in 4 weeks from your original appointment and results cannot be guaranteed if you do not attend. You may reschedule with 24 hour advance notice within a 6 week period. Additional Touchup appointments will incur a fee.

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3. It has been explained to me and I understand that minor and temporary bleeding, bruising, redness, swelling, fading, or loss of pigment may occur: There is a rare risk of infection, missed place pigment, allergic reaction, fever blisters, corneal abrasion and/or color change with any cosmetic micro pigments.

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4. If I had a permanent cosmetics procedure performed previously by another practitioner, I do not hold JMP Ventures LLC or its employees responsible for future allergic reactions or fading and changing color of pigment.

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5. I have informed JMP Ventures LLC of any healing Problems, Medication or Disease.

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6. I understand that JMP Ventures LLC and its employees cannot guarantee the outcome of any permanent makeup procedure due to the unpredictability of the human skin.

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7. I accept responsibility for helping to determine the color, shape, and position of eyebrows, Eyeliners and lip liner/full lips.

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8. I have received, reviewed and understand the post procedural instructions as given to me and follow them. I understand the importance of strictly adhering to such instructions.

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9. I understand that lip augmentation, Botox, Restlyne or any cosmetic surgery can make it so there may be several session required and that future augmentation may change the positioning of my permanent makeup.

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10. If I am a contact lens wearer, I realize that I must keep my lenses out the day of any eyeliner procedure.

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11. If I insist on driving, I waive all responsibility to my practitioner and I assume full responsibility that I can see to drive, perfectly.

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12. I understand that this procedure will fade and sometimes just not take to the skin at all even after several applications. I understand this and still agree to proceed with this service. I understand there are no refunds or free services. I understand this fading can alter the original pigment color due to circumstances beyond the control of JMP Ventures LLC.

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13. I understand that I will need to maintain the color with future Touchup applications. We do not know nor can we guarantee how long these Touchup applications may be required. I understand the natural oils in a person’s skin, some medications, sun, skin care products, pool and other factors play a role in fading as mentioned in the after care instructions.

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14. I realize this is an elective cosmetic procedure, not an exact science, and is not medically necessary. There are no refunds, no free services and no exceptions, upon treatment for this elective procedure.

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15. I authorize JMP Ventures LLC unrestrictive use of before and after photographs to include but not limited to portfolio and teaching. JMP Ventures LLC must have photos of all clients.

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16. I give my consent to JMP Ventures LLC to confer with my physicians for medical information required for the safety of my procedures.

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17. I understand that many lasers & IPL's (Intense Pulse Lights) including those used for hair removal, anti aging, Photo Facials, removal of lines may or will turn permanent make up color dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up.

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18. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have Iron Oxide Permanent Cosmetics.

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19. I agree to accompany my practitioner at JMP Ventures LLC to the emergency room in the event to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner.

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20. I am aware that if an infection occurs after I have received Permanent Cosmetics I will see Care Physician or an emergency room, immediately.

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21. I am aware that JMP Ventures LLC will use new pre sterilized needle(s) and pigment(s) for all procedures and will follow OSHA standards and on all client's new gloves are worn for all procedures.

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22. I understand that a patch test does not guarantee that I may not develop and allergic reaction in the future.

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23. I understand the fee that JMP Ventures quotes for the procedure I've requested, includes one follow up visit to complete the original work. I understand that everyone's skin is different and may require additional visits for more color application to achieve desirable results. Additional visits will incur an additional fee.

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24. I have received no unrealistic warranties or guarantees with the respect to the procedure being performed.

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25. Your signature below represents consent for Permanent Cosmetic services and shall remain in effect during the entire period you remain a client of JMP Ventures LLC.

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26. I acknowledge by signing this consent form. I have been given the full opportunity to ask any and all questions about permanent makeup procedures and processes from my permanent cosmetic technician.

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To makeup practitioner and/or her associates

I have read and understand these risks listed above and they have been explained to me. I DID NOT JUST SIGN THIS DOCUMENT. I certify that the information in the above questionnaire is accurate and that is has been explained to me in detail and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request. I agree that I will give 24 hour notice if I need to cancel or I will forfeit my $50.00 deposit. I understand that my practitioner has a right to refuse service and that If I no show to my appointment there with be an additional deposit required to reschedule.

No minors allowed in the treatment room and no more than one person May acompany you.

WE DO NOT TATTOO MINORS AT THIS ESTABLISHMENT!

If under the age of 18, Please wait in Waiting room accompanied by adult. We ask that you reschedule if you have a minor with you and there is not an adult to accompany them in the waiting area.

I personally reviewed the above information with my client, or client's representative.

We do have a large waiting area to accommodate.

APPOINTMENT POLICY A consultation visit is free of charge. A 24 hour notice is required to reschedule a consultation appointment. If you fail to cancel/reschedule this appointment within this time frame, a $50 prepaid deposit is required to schedule another consultation. The $50 deposit will be applied toward any procedure of choice. Please do not bring children to appointment(s). After the consultation, a written price quote and a copy of these appointment policies are given. Clients are never pressured to schedule a procedure. In fact, all procedures should be carefully considered before scheduling them. To reserve an appointment for a procedure, a deposit of $50 is required. The deposit will be applied toward the cost of the procedure. Pregnant or nursing women or anyone under the age of 18 will not be considered for tattooing. Please advise me now if any of these apply. If an appointment must be rescheduled, a 24 hour notice is required in order to fill the opening in the schedule. The deposit will be applied toward the rescheduled appointment. However, if you fail to reschedule and not come at your appointed time, the deposit will not be refunded or reapplied. The full price of the procedure will be due with another procedure at time of deposit. The first visit of the process is the initial Saturation visit. The following visit is known as the Focus visit. As the names imply, the Saturation visit accomplishes the basic design and color saturation, and the Focus visit addresses perfection by focusing on balance, symmetry and detail of the healed result. There is no hourly charge for the Focus visits as long as they are completed within 30 days of the previous visit. There are additional fees if not completed within this time period and we cannot guarantee our work if you do not attend your mandatory second visit. A cancellation/rescheduling of a Focus visit is required 24 hours in advance. If you fail to reschedule and not come at your appointed time, the complimentary pre-booked Focus visit is forfeited and an up Front Deposit of $150 ($50 additional hourly rates apply) per follow up procedure will be required. Please respect our time and our other clients time. Your Second Color Assessment appointment should be scheduled at the end of the first year and if a Touch-Up is needed, the charge is $275 per procedure. If, at the first year assessment, the touch-up is determined unnecessary, the charge for the second year touch-up is $300. The length of time one waits in between touch-up visits will determine all fees.All color fades and your cosmetic tattoo will require maintenance. The amount of fading depends on several variables including medications and topical treatments, but is primarily due to sun (ultra-violet) exposure; therefore measures should be taken to protect your permanent cosmetics from the sun. I will not ask for a refund or hold accountable nor responsible any employee of JMP Ventures LLC if I decide to see a different artist outside of JMP Ventures LLC for my touchup service. I, the undersigned, received these appointment policies both verbally and in written form and I agree to comply with them. My signature is my consent to charge the aforementioned $50 non refundable deposit against my credit card should I decide to reserve an appointment.

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Please Sign Below Arbitration Agreement

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Name

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Signature

Clear

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“Practitioner leave Blank” Fees for Procedure

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“Practitioner leave Blank” Machine/level

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“Practitioner leave Blank” Pigment/Lot/Exp. Date

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“Practitioner leave Blank” Needle(s)/Lot/Exp. Date

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“Practitioner leave Blank” Anesthesia (Primary & Secondary) Lot/Exp. Date/time on

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“Practitioner leave Blank” Tolerance Level (L/M/H)

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“Practitioner leave Blank” Fees for Service

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NameOf Technician “please leave Blank”

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SignatureOf Technician “please leave Blank”

Clear

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Date

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Photo ID Front

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Photo ID Back

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I.D. VerificationName of Practitioner “leave blank”

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Date

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Signature of Permanent Cosmetic Practitioner Here: “Please leave Blank”