Timeless Makeup, LLC

Transcription

1 Timeless Makeup, LLC CLIENT REGISTRATION (Please complete all blanks) I. CLIENT INFORMATION Name Date Address City Zip Phone number address Type of work Ethnicity Date of birth What was your hair color as a child? In the sun, do you (circle one) :TAN EASILY - BURN THEN TAN - ALWAYS BURN Other Would you say your skin is ( underline one): OLIVE - FAIR - TRANSLUCENT WITH A CLEAR BLUE UNDERTONE - RUDDY RED - NATIVE AMERICAN WITH A WARM UNDERTONE - GOLDEN PEACHES AND CREAM - ASIAN WITH A SALLOW TONE - BLACK Emergency contact information Name Phone How did you hear about me? Why do you want permanent makeup? II. PHOTO RELEASE I authorize my technician performing this procedure and/or the owner of the establishment where this procedure is being performed unrestrictive use of before and after photos to include but not limited to portfolio and explaining procedures. Initial III. MEDICAL HISTORY Physician's name City or phone Please list all prescriptions, herbs, and vitamins that you are taking: Do you wear (circle any that apply):contact LENSES-EYEGLASSES- DENTURES

2 Have you recently undergone or plan to undergo any elective or necessary facial surgery or laser procedures? If yes, please explain. Have you ever had permanent makeup applied before? (Circle one) YES - NO If yes, what procedures? By whom? How long ago? Were you pleased with the result? If not, please explain why. What would you like to achieve with your permanent makeup? Do you have any known allergies? If yes, please list them (Please write YES or NO in the following blanks.) Are you allergic to: Latex Glycerin Paba Epinephrine Caine Products Other Do you have any lip implants, gotex, collagen, or other? Have you had botox injections? If yes, where on the face? When? Do you use "all day" long lasting lipsticks? (i.e. Lip sense of lip ink) YES - NO If so, STOP, because they dry out the lips. If you re having a lip procedure, then your lips will be tough, making implanting pigment more challenging, if not, impossible. Stop wearing this type of lipstick and start exfoliating the lips by lightly brushing lips after brushing teeth. Please wear a moisturizing lip balm to soften them. If you wear there types of lipsticks, as you may have to post pone your lip procedure until the lips are in better, softer condition. I have disclosed all necessary information to my technician before beginning any procedure. (Initial) Do you use Retin- A, Renova, or glycolic acids regularly? By initialing below, I am acknowledging that I have stopped use two weeks prior to this/these procedures, and am aware that I cannot resume use of these products, until 14 days after my final touchup. (Initial) I have never used accutane, and/or I have been off accutane for at least 12 months. (Initial) I am aware that laser treatments have the possibility to fade my permanent makeup, and/or turn it black (Initial)

3 Do you take any of the following medications? (Please circle all that apply) ACCUTANE - INSULIN - BLOOD THINNERS - ANABUSE - STEROIDS - ASPIRIN - HIGH BLOOD PRESSURE - ANTI-COAGULANTS Do you need to take antibiotics prior to seeing your dentist? YES - NO Have you EVER, at ANY time in your life, had a cold sore? YES - NO If yes, I agree that I have taken a prescription medication from my doctor or dentist that prevents cold sore outbreaks if I am have a lip procedure done. I have been using Valtrex, Famvir, or Zovirax as advised by my doctor, and will use during, and after any lip procedures, including touch-ups. Fever blisters can occur with any lip procedure. (Initial) I am aware that I should not tan immediately before, or after my permanent makeup appointment.(initial) Please write YES or NO on the following blanks. If YES, please elaborate for your technician, to ensure there are no contraindications. DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? Blepharitis (Inflammation of the eyelid) Autoimmune Disorder/s (a condition that occurs when the immune system mistakenly attacks and destroys healthy body tissue.) Mental Illness (Any psychiatric disorder that causes untypical behavior.) Dry Eye Syndrome (a condition where the body is not able to produce enough tears to protect the front surface of the eye to provide quality vision. This condition is more common for contact wearers, computer users, previous eye surgery patients, and those over 55.) High Blood Pressure (also called hypertension that occurs when your blood moves through your arteries at a higher pressure than normal.) Dermatitis (a condition of the skin in which it becomes red, swollen, sore, sometimes blisters, resulting from direct irritation of the skin by an external agent or an allergic reaction. Compare with eczema.) Lupus (when the immune system becomes overactive and attacks healthy cells and tissue by mistake.) Thyroid (a medical issues with the body gland in charge of metabolism and growth.)

4 Metal Allergies (an allergic reaction to metal, usually referenced in the form of jewelry. Although different types of metal can cause allergies, most people have reactions to nickel. SofTap pigments contain iron oxides, as long as there is no allergy to iron, a contraindication may not be the case, if a patch test is performed properly.) Hemophilia (a condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.) Chemotherapy (the treatment of disease by the use of chemical substances, especially the treatment of cancer by cytoxic and other drugs.) Pregnancy (if you may be pregnant or are currently pregnant, your service will have to be rescheduled until after you give birth, and are done breast feeding.) Diabetes ( a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and the urine.) Alopecia (Hair loss, also known as baldness.) Cancer (if you have been diagnosed with active cancer, you will have to reschedule your service until you have been healed, or obtain a doctor's note for your technician before the procedure can begin.) Conjunctivitis (also known as pink eye, your service will need to be rescheduled and your technician will not be able to perform this service until you are healed.) Mastectomy (a surgical operation to remove a breast; if you are currently having a mastectomy, your permanent makeup procedure will need to be rescheduled when you are healed from the trauma.) Epilepsy (a disorder marked by sudden recurrent episodes of loss of consciousness or convulsions. Make your technician aware of the severity of your epilepsy if you have it.) Heart Problems (Make your technician aware of any heart problems you have, the severity, and obtain a doctor's note if it is a severe issue.) HIV (If you have been diagnosed with HIV, you will need to obtain a doctor's note for your technician to save on file before having any permanent procedure performed on you.) Eye Disorders (if you have an eye disorder of any type, let your technician know if your have have eyeliner applied, to determine if there may be a contraindication.)

5 Blood thinners ( a common name for an anticoagulant agent used to prevent the formation of blood clots. Blood-thinners do not actually thin the blood, they prevent it from clotting. **Refer to hemophilia.) Cosmetic allergy (If you have had an allergic reaction to any cosmetics in the past, inform your technician and determine if a patch test is necessary in order to perform your service safely.) Hormone Therapy (inform your technician of the severity of your hormone therapy to determine if a doctor's note is necessary to perform your service if necessary.) Hepatitis (inflammation of the liver.) Scar tissue (the absorption of pigment over a scar is never able to be anticipated, all scars heal differently, and there is no guarantee that permanent makeup will "solve" discolored scarred areas.) Lip Implants, Lip Injections (Inform your technician of all implants and injections, so any risks or possibilities can be explained to you.) Seizures (inform your technician if you have recurring seizures.) Keloids (an area of irregular fibrous tissue formed at the site of the scar or injury; people who keloid are NOT a good fit for these kind of procedures, ask your technician why.) Radiation (If you are actively participating in radiation treatments, you will need to reschedule you service for when you are recovered and healed, or obtain a doctor's note for your technician to keep on record. ) Cold Sores ( you must be on a medical prescription for preventing cold sores for all of your treatments, if you are having your lips worked on.) Healing Problems (if you have any sort of healing problems, discuss them with your technician.) Trichotillomania (a compulsive desire to pull out one's hair; if you have this condition, you must talk to you technician about why it's so important not to pick the scabs or pull hair out from un-healed areas after having permanent makeup applied.) Bruising (If you bruise easily, inform your technician.) Hematoma ( a solid swelling of clotted blood within the tissues; must discuss this with your technician.) Glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight. A doctor's note MUST BE OBTAINED in the case of a glaucoma.) Bleeds easily (Inform your technician if you bleed more easily than the average person.)_

6 Please list any other major medical conditions IV. STATEMENT OF CONSENT AND RECITALS Please initial all lines Before and after instructions have been explained orally and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If i have any questions I will call the technician who performed my procedure. I understand that a certain amount of discomfort is associated with this procedure and that minor and temporary swelling, redness, or fever blisters may occur on the lips following lip tattoo procedures in individuals who are prone to this problem. Fading or loss of pigment can, and will occur. I understand that permanent makeup is a multi-session procedure requiring more than one visit to perfect. All procedures take at least 30 days to heal and re evaluate. I understand that sun, tanning beds, pools, anti aging skin care products (Retin A, Renova, etc) and medications can affect my permanent makeup. I understand that Retin A or Renova must not be used around the treated areas long term. I must stop using 2 weeks prior to my sessions. I understand that I must be off accutane 12 months prior to the procedure/s. I understand that successful lip, brow, and eye saturation cannot be guaranteed due to hidden scar tissue. I understand that it is my responsibility to obtain a prescription from a doctor or dentist for a fever blister medication to help avoid outbreak. I understand that I must wait one year following any application (tattoo) to donate blood. I understand that I must inform all skin care professionals, medical personnel, of other cosmetic tattoo technicians of all permanent makeup treatments. I understand I must inform all medical personnel about my permanent makeup prior to an MRI. I accept the responsibility for explaining to the performing technician my desire for specific color, shape and position for eyebrows, eyeliner, lips, and camouflage/areola restoration. I understand that permanent makeup is an art and not a science, the performing technician cannot guarantee the outcome of this procedure. The reason is that there are so many variable related to the client, i.e. following the aftercare instructions, sun exposure, everyday environmental factors, medications taken, anti-agin creams, client s medical condition/s, etc. I understand that implanted pigment will fade over time and possibly turn color due to circumstances beyond the control on the performing technician and alter the original pigment

7 color. I understand I will need to maintain the color with future applications. Sun, skin care products, pools, and other factors play a role in pigment fading on the face. The nature of the proposed permanent makeup procedure has been explained to me. All risks and possible complications have been explained to me. I acknowledge that the proposed procedure/s all involve risks inherent in the procedure and the possibility of complications during and following the procedure. Infection, misplaced pigment, poor color retention, hyper pigmentation, migration, and/ or fever blisters. I hereby consent to having permanent makeup applied by Renee Dotson. I have answered all questions honestly and to the best of my knowledge. I understand I can have an allergy patch test by request, but that years from now, an allergic reaction could still possibly occur. I certify that I have read and understand all of the above. V. ARBITRATION AGREEMENT In the event of any controversy/ disagreement between client and the technician, involving a claim or "tort" and all other "claims," the same shall be submitted to arbitration. Within fifteen days after the client and the technician shall give notice to the other of demanding arbitration of such controversy, the parties to the controversy shall appoint an arbitrator and give notice of such appointment to the other. Within a reasonable amount of time after such notices have been given, the two arbitrators, so elected, shall select a neutral arbitrator and give notice of the selection thereof to the parties. The arbitrator shall hold a hearing within a reasonable amount of time from the date of selection of neutral arbitrator. All notices of other papers required to be served shall be served by the United States mail. (initial here) I have paid Renee Dotson / Timeless Makeup, LLC the amount of $, for the procedures (circle all that apply) PERMANENT UPPER EYELINER - PERMANENT LOWER EYELINER - PERMANENT FULL EYE LINER - PERMANENT BROWS - PERMANENT LIP LINER - PERMANENT FULL LIP FILL IN - CORRECTIVE WORK - TOUCH-UP FROM PREVIOUS APPLICATION/S I understand there will be no refunds after treatment of this elective procedure/s. I understand my payment includes a total of two visits within 30 to 45 days of initial application. It is the responsibility of the client to contact the technician within 30 days after any session if a touchup is required. Be sure to book touchup if needed within 2 weeks advance notice, to ensure an available spot.

8 NOTE: if client only has one application, then decides 3 months later that she wants her second application, there will be a $150 charge per procedure. Why? Permanent makeup needs to be layered on so fading doesn't occur so drastically. Usually, a total of 2 applications are required to achieve the final outcome. The touchup applications ideally should be 4-6 weeks apart, no longer than 3 months apart. Additional touchups cost $75 per visit. In the future, additional visits for current client touchups occurring within 365 days will only cost $250. This will range on individual basis from 1 to 5 years. Signature of Client Date Signature of Technician Date Timeless Makeup, LLC 1201 N. Main Avenue, Ste 104, Durango, CO (970)

9 Technician s Report 1.) Procedure: LIPS - EYELINER - EYEBROWS - BEAUTY MARK - TOUCHUP Pigment brand Pigment color Technique and needle size/s Complications: YES - NO Explain: Tolerance Level: LOW - MEDIUM - HIGH Time in Time out Numbing agent/s used: NUMBPOT - TAG 45 - MINERVA - NUMBQUICK PINK - DOTC 2.) Procedure: LIPS - EYELINER - EYEBROWS - BEAUTY MARK - TOUCHUP Pigment brand Pigment color Technique and needle size/s Complications: YES - NO Explain: Tolerance Level: LOW - MEDIUM - HIGH Time in Time out Numbing agent/s used: NUMBPOT - TAG 45 - MINERVA - NUMBQUICK PINK - DOTC 3.) Procedure: LIPS - EYELINER - EYEBROWS - BEAUTY MARK - TOUCHUP Pigment brand Pigment color Technique and needle size/s Complications: YES - NO Explain: Tolerance Level: LOW - MEDIUM - HIGH Time in Time out Numbing agent/s used: NUMBPOT - TAG 45 - MINERVA - NUMBQUICK PINK - DOTC