Touch Up-Color Refresh Policy
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- Terence Flynn
- 5 years ago
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1 Touch Up-Color Refresh Policy All Full Price New Procedures clients receive one Follow up visit for $50 with your initial price per procedure. You must wait at least 30 days before you can be touched up. You MUST have your touchup within 90 days of your initial visit. Anyone not having their touchup done within 90 days will have to pay a full Color Refresh fee for their follow up. Color Refresh fees are ½ the full current price per procedure. Signed Date Print Name Date you must have your touchup by Color refresh fee if applicable after 90 days Staff Signature Date Asheville Permanent Makeup Clinic 131 McDowell St Suite 202 Asheville NC *Touchups are only applied to FULL PRICE PROCEDURES. You DO NOT get a touch up with Color Refresh appointments.
2 Client Contact Info Date Name Home Phone Work Phone Cell Phone Address City State Zip Who referred you? Date of Birth Age Would you like to receive updates / newsletters and specials? Yes We do not sell our mailing list, but you may receive mailings from Asheville Permanent Makeup Clinic or Beauty Through Cancer as part of Asheville Permanent Makeup s mission to help cancer patients.
3 Client History Physician s Name? Phone? Please List All Medications You Are Taking Please List Any Allergies To Medications Please circle and explain all that apply: Are you pregnant? No Yes Have you had alcohol in the last 24 hours? No Yes Have you had cold sores or fever blister? No Yes Have you had permanent makeup or tattoos before? No Yes Have you had chemical or laser peels in the last 6 months? No Yes Do you have any allergies to latex? No Yes Do you bruise easily? No Yes Do you use Retin-A or Glycolic products? No Yes Do you wear contact lenses? No Yes Do you have any trouble healing from small wounds or scratches? No Yes Do you use tobacco? No Yes Do you have a heart condition? No Yes Are You Diabetic? No Yes Type 1 Yes Type 2 Do you have an auto-immune disorder? No Yes Are you sensitive to hand lotions or creams? No Yes Do you have your lips injected with fillers? No Yes Are you menstruating? No Yes
4 Do have dark spots from the sun? No Yes Do forms thick scars after a cut? No Yes Do you have any conditions that cause seizures? No Yes Do easily become faint or dizzy? No Yes Do you bleed easily from minor cuts? No Yes Do you have prosthetic implants? No Yes Do you take aspirin daily? No Yes Are you being treated for depression? No Yes Are you sensitive to petroleum based products, Vaseline type? No Yes Do you have Botox injections? No Yes Are you undergoing radiation or chemotherapy? No Yes Have you ever used Accutane? Are you using it now? No Yes Are you wearing a pacemaker? No Yes Do you take non prescription drugs? No Yes Are you anemic? No Yes Are you allergic to traditional makeup? No Yes Do you have trouble numbing at dental visits? No Yes Do you have dry eyes? No Yes Do you tan? No Yes How often? Do you have any history of cancer personally? No Yes Do you have glaucoma, cataracts, or any other eye conditions? No Yes Do you have arthritis? No Yes Do you have high or low blood pressure? No Yes Do you have sinus problems? No Yes Do you have any type of hepatitis? No Yes Do you get headaches or migraines? No Yes Are you sensitive to bright light? No Yes
5 Please List the procedures you are having today Please List any questions or concerns you may have about your procedure so they may be addressed before your procedure begins. The following is a consent for permanent cosmetic procedures, please read carefully and sign or initial where needed: I understand I may or may not have an allergic, or negative reaction to the pigments or anesthetics used in my permanent makeup procedure, either immediately or in the future. I will not hold Asheville Permanent Makeup Clinic, Earleen Bennett or her estate liable for negative reactions as they can not be predicted. I understand this is an elective procedure and I choose to have cosmetic tattooing done at my own risk. I understand before and after pictures must be taken and may be used in advertising, portfolios or on website and published materials. I choose to have the following type photos used: (Initial Below) Full Facial Features No restrictions Procedure area only, No Full Face Photos I have advised Earleen Bennett of ALL medications I am taking at appointment time. I acknowledge I am of sound mind and not under the influence of alcohol or mind altering drugs. I understand This consent form will be used for all present and future procedures done at Asheville Permanent Makeup Clinic by Earleen Bennett and I will not have to sign a new consent for future appointments. I understand this is a tattoo procedure, and that is an art as well as a science. I understand that the exact length of time my makeup will last cannot be predicted and will be different for each client. I understand I WILL need touch up appointments in the future to retain color. I understand more than one appointment may be needed. I understand the policy of a $50 charge for touchups within 90 days of initial appointment. I understand if I do not have the $50 touchup appt within 90 days of initial appt I will be charged full touchup price. I understand full payment is due at initial appointment time of service. I understand I must be pre medicated for cold sores if I have ever had an outbreak and it is my responsibility to obtain prescriptions from my doctor and take them as advised by him or her.
6 I understand it is my responsibility to discuss medication changes with my physician in the case a medication interferes with a procedure being performed. I understand I may need a release from my physician for certain procedures if so deemed necessary by Earleen Bennett. I will adhere to all pre and post procedure instructions. I understand my failure to do so may jeopardize my chances for a successful permanent cosmetic procedure. I understand if I have any laser procedures or certain cosmetic surgery procedures done in the future it may alter the placement or coloring of my permanent cosmetics. These changes may not be correctable. I understand lifestyle choices such as sunbathing, use of exfoliating products, glycolic peels, smoking and certain medications can change the appearance of my permanent cosmetics and may make it necessary for more frequent color touch ups. I ACCEPT FULL RESPONSIBILITY FOR THE DECISION TO HAVE COSMETIC TATTOO PROCEDURES PERFORMED: CLIENT SIGNATURE Date PRINT NAME Technician Signature Date Asheville Permanent Makeup Clinic 131 McDowell St Suite 201 Asheville NC Owner Earleen Bennett
7 Asheville Permanent Makeup Clinic - Policies Each FULL PRICE NEW procedure allows for ONE touch up visit at a charge of $50 Tray Set Up Fee within 90 days of initial service. Returning established client fees for retouching color after 90 days is 1/2 the full procedure price posted at that time. Any returning client must pay full price after a 5 year period, or if all color has faded. A consultation may be necessary to establish price before your procedure. If you are not an established client with a file in our clinic, you must pay full price even if you have had a service in the past from another technician. Discounted one time touch up fees are ONLY for established clients. There will be a $50 minimum tray set up fee for any small services or time booked other than the $25 consultation. No Show appointments will be charged $50 to reschedule appointment. No One under the age of 18 will be tattooed. You will be given consent and medical forms which MUST be completed and signed before any tattooing will be performed. Please READ the forms before you sign them as there are risks to any procedure. You will be given after care instructions to follow, please read and follow all instructions to assure a good outcome. There is NO GUARANTEE on how long your permanent makeup will last. You WILL need touchups in the future to keep you color looking fresh. Your procedure time is not a social occasion, no one is allowed in the procedure room at the time of your procedure, there is a waiting area. Exceptions may be made for breast cancer patients during areola pigmentation. I reserve the right not to tattoo anyone who does not comply with these policies, or arrives at their appointment intoxicated or impaired in any way. I may need to contact your physician for certain health matters before a procedure is performed and I may require a written release from your doctor if I think your health may impact your procedure. The clinic accepts cash, checks, Visa, and MasterCard. Policies and pricing are subject to change without prior notice. Please see our website for current policies. Asheville Permanent Makeup Clinic 131 McDowell St Suite 202 Asheville NC
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MARK D. EPSTEIN, M.D. F.A.C.S. Hyaluronic Acid (HA) INJECTION - INFORMATION FOR PATIENTS
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CLIENT QUESTIONNAIRE
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SOUTH BAY LIPO LIGHT
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Health Questionnaire
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IF YOU GET FILLERS, THEY SHOULD BE DONE 6 WEEKS PRIOR TO YOUR SCHEDULED PROCEDURE OR DONE 6 WEEKS AFTER THE PROCEDURE.
If you have had Permanent Makeup previously done and fail to tell us, Elena reserves the right to refuse service and may recommend removal Her signature hair stroke technique will not work over dark, solid,
Last Name: First Name: Address: Apt: City: State:
Today s date: Estimated Weight Height Last Name: First Name: Address: Apt: City: State: Zip Phone: (H): (C) (W) Email: Please note, email will not be given to others and will only used for reminders and
HISTORY CARD. [ ] Face: Nose [ ] Face: Sideburns [ ] Glabella [ ] Gluteal [ ] Hands & Feet
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HISTORY CARD Name: Date of Birth: / / Street Address: City: State: Zip: Telephone: (Home) Email: MEDICAL HISTORY Are you under a doctor s care: Yes [ ] No [ ] Please list any recent surgeries/injuries: