CLIENT INTAKE FORM
Permanent Makeup/Scar Revision/Areola Restoration
CLIENT INFORMATION
Name:
Date:
-
Month
-
Day
Year
Date
Date of birth:
-
Month
-
Day
Year
Date
Age:
Female
Male
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Email:
example@example.com
Emergency contact:
How did you hear about us?
MEDICAL HISTORY
Do you have or have you had any of the following conditions? If yes, please select them:
Medical Conditions
Autoimmune Disorder
Eczema
Kidney disease
Aids/HIV
Eye surgery/injury
Liver disease
Bleeding Disorder
Glaucoma
Pregnant/breastfeeding
Cancer
Hemophilia
Psoriasis/Dermatitis
Cardiac Valve Disease
Hepatitis
Radiation
Chemotherapy
Herpes/Cold Sores
Skin condition
Depression/Mood disorder
History of MRSA
Serious Heart Condition
Diabetes
Hypertronic Scarring/Keloids
Other
Do you have any allergies:
No
Yes
List any medications/supplements you are currently taking:
Have you taken any of the following in the last 2 days: Aspirin, Ibuprofen, Coumadin, Alcohol?
No
Yes
Do you wear contact lenses?
No
Yes
Do you often have eye irritation, itching or watery eyes?
No
Yes
Back
Next
CLIENT INTAKE FORM
CLIENT HISTORY
Have you had any permanent or semi-permanent makeup services done before?
No
Yes
If yes, what kind of permanent makeup have you had?
Have you had any services done on area being treated in the last 30 days?
No
Yes
Have you recently done a chemical peel?
No
Yes
If yes, when?
Are you currently wearing lash extensions?
No
Yes
Do you have a tanned/sunburnt skin?
No
Yes
Have you used Latisse or any eyelash/eyebrow growth conditioner within the last 2 months?
No
Yes
Have you received Accutane (acne medication) within the last year?
No
Yes
Have you received Botox in the last 2 weeks?
No
Yes
Have you used Retin-A, Renova, AHA, BHA, Retinoid or Retinol products in the last 3 months?
No
Yes
Have You received lip fillers in the last 12 weeks (Lip Blushing Only)?
No
Yes
Please list any allergies, questions or concerns.
By signing below, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition/s that would make the requested treatment unsuitable. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health.
Technician (signature)
Client Name (signature)
Date
-
Month
-
Day
Year
Date
PAGE 2/2
Back
Next
I hereby consent to and authorize
following procedure:
to perform the
Although every precaution will be taken to ensure your safety and well being before, during and after your procedure, please be aware of the following information and possible risks.
Please initial each statement:
I am over the age of 18 and in sound mind, body, and health.
I understand that I will have permanent makeup (referred to on this form as PMU) applied using the highest standards of hygiene and that sterile, disposable needles and pigment containers are used for each individual client, procedure, and visit.
I understand and accept that permanent makeup is a process, often requiring multiple treatment visits to achieve desirable results and 100% success cannot be guaranteed.
I have been advised that the pigment result may vary according to skin tones, skin type, ethnicity, age, lifestyle, post-procedure care and general skin conditions. And I understand no guarantee on exact color results can be given.
I am aware that the true healed color will be visible 6-8 weeks after each procedure.
I accept the responsibility for determining and agreeing to the color, shape, and position of the PMU procedure as agreed upon during the consultation.
I fully understand and accept that non-toxic pigments are used during the procedure and that the results will fade over time, however, some trace pigment may stay in the skin indefinitely.
I have been advised that touch-ups are encouraged to maintain the integrity of the color.
If an unforeseen condition arises in the course of the PMU procedure, I authorize the technician to use his/her professional judgment in deciding what she feels is necessary under the given circumstances.
I can confirm that I have received before and aftercare instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.
PAGE 1/3
Back
Next
If I wear contacts, I am aware that I must remove them prior to an eyeliner procedure.
I am aware that I must remove any false eyelashes prior to an Eyeliner/Lash Enhancement procedure. I am also aware that any lash enhancement serums or conditioners can affect the outcome of my Eyeliner/Lash Enhancement procedure
I acknowledge that my skin is vulnerable to infection directly after a PMU application, and I am to contact my primary physician if I see any signs of infection.
I understand that using cosmetics, excessive perspiration, and sun exposure should be limited until the skin has fully healed.
Allergic reactions are always a possibility. I understand that a patch test/allergy test does not guarantee that I will not have an allergic reaction and I release the technician from liability should I develop an allergic reaction to any of the topical preparations, pigments, inks or the anesthesia used in the procedure.
I understand it's impossible to list every potential risk and complication. I agree to have been informed of possible benefits, risks, and complications including but not limited to: redness or other discoloration, temporary bleeding, bruising, swelling, irritation, pain, fading or loss of pigment, and cold sores on lips.
I am aware that if I am to have an MRI after the procedure, I must tell the radiologist that I have permanent cosmetics.
I understand that laser hair removal procedures may turn lip pigment dark or black.
I understand the positioning of my PMU procedure can be affected if I elect to have cosmetic surgery, Botox, Restylane or other cosmetic or surgical procedures.
I understand that correcting or touching up PMU that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors that my technician has no control over. I understand that additional appointments after the initial and follow up appointments may be required.
I acknowledge that the procedure may result in a long lasting (many years) change to my appearance. I acknowledge that The Brow Haus is not responsible to remove any such procedure.
Back
Next
CLIENT CONSENT FORM
I consent to the taking of before and after photos for the purpose of record keeping & documentation required by the Technician's insurance company.
I further authorize that exceptional photographs or results may be used in advertising or promotional materials and I give permission for such usage.
I am not pregnant or nursing and am not under the influence of any drug or alcohol at this time.
All medications and medical conditions have been disclosed to my technician as well as noted accurately and to the best of my knowledge on my intake/consultation form.
Being of sound mind and body, I hereby release and forever discharge the Technician at ____________________ from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my PMU procedure. I fully accept any and all responsibility for any consequences that might stem from my decision to have a PMU procedure performed by ____________________
By signing below I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that 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 liability toward my technician and the salon for any injuiry or damages incurred due to any misrepresentation of my health.
This agreement will remain in effect for this procedure and all future follow-ups conducted by the technician. I understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the PMU procedure.
Technician (signature)
Client Name (signature)
Date
-
Month
-
Day
Year
Date
PAGE 3/3
Back
Next
EYEBROWS
PRE-CARE INSTRUCTIONS
PRE-CARE ADVICE
No alcohol for at least 24 hours before the procedure.
No caffeine on the day of the procedure.
No blood thinners including pain killers for at least 24 hours before the procedure.
No aspirin, ibuprofen or aleve for at least 48 hours before the procedure.
No working out on the day of the procedure.
No sauna or tanning 14 weeks prior.
You cannot be pregnant or breastfeeding.
Discontinue use of fish oil or vitamin E at least one week prior.
No botox injections in the brow area for at least 2 weeks prior to the procedure.
No deep exfoliation in the brow area for at least 2 weeks prior to the procedure
No retinol products, acne treatments or salicylic acid in the brow area for at least 4 weeks prior.
No antibiotics at the time of your appointment. (or 14 days prior)
No eyebrow tinting 2 weeks prior to the procedure.
A patch test will be performed prior to the procedure unless waived.
No waxing 14 days prior. Electrolysis no less than five days before the procedure.
Since delicate skin or sensitive areas may be swollen or red, it is advised not to make social plans for the same day.
WHAT TO EXPECT
Immediately the days following your procedure, the tattooed area will appear to be darker and bolder in color and more sharply defined. The complete healing process takes about 6-8 weeks, at which time the true color of the tattoo is evident. During this process, your tattoo will soften and lighten. Be patient and wait at least 6 weeks to see the true color.
PAGE 1/3
Back
Next
EYEBROWS
AFTER-CARE INSTRUCTIONS
AFTERCARE ADVICE
Should be Empty: