Permanent Makeup Intake Form

Transcription

1 Permanent Makeup Intake Form Artist Information (the Artist ): Chrystal Ladouceur 1530 McTavish Road, North Saanich, B.C., V8L 5T3 Client Information (the Client ): First Name Mobile Phone Address City / Prov. Date of Birth Last Name Home Phone Postal Code Today s Date How did you hear about my services? Which procedure are you here for today? Health History The below questions are relevant to the Permanent Makeup Application (the Procedure ). Please answer each question truthfully. A yes answer does not indicate that you are not an acceptable candidate for permanent cosmetics, but may indicate that modifications to the application procedure be need to be made, or may dictate that a primary physician s approval should be sought prior to application, and/or may determine that healing differences should be expected. Have you ever had any permanent cosmetics or tattoos applied? If yes, please share details below Yes No If you have permanent cosmetics or tattoos did you have problems healing after they were applied? Yes No Do you routinely use Glycolic Acid, Retin-A/Retinol, or Alpha Hydroxyl Acid, or other exfoliating products? Yes No Do you receive cosmetic injections (Botox or lip fillers, etc.)? If yes, please note the procedure details and date of last injection in the space provided below. Yes No Have you had a laser or chemical peel within the last 6 months? Yes No Do you intentionally tan (in a tanning bed or natural sun light)? Yes No Do you consume aspirin or other blood thinners daily? Yes No Are you taking prescription medications? If yes, please list medications in area provided below. Yes No Are you pregnant or nursing? Yes No Do you have allergies to topical make-up? Yes No Are you sensitive or allergic to hand creams or body lotions? Yes No Do you have a history of Methicillin-resistant Staphylococcus aureus (MRSA)? Yes No Do you have allergies to latex? Yes No Do you have any autoimmune disorders? Yes No Are you allergic or sensitive to metals? Yes No Do you have any problems healing from small wounds? Yes No Do you smoke cigarettes? If you are a smoker, you may heal slower. Yes No Are you Diabetic? If yes, please note Type 1 or Type 2 below. Yes No Do you hyper-pigment (have a tendency to develop dark spots on the skin from wounds or sun exposure)? Yes No Do you hypo-pigment (lack of pigment on the skin - Vitiligo)? Yes No Do you develop keloid or hypertrophy scars? Yes No Do you scar easily from minor skin injuries? Yes No

2 Do you bruise easily? Yes No Do you bleed excessively from minor cuts? Yes No Do you have a history of skin sensitivities? Yes No Do you have psoriasis? If yes, please indicate below where outbreaks occur. Yes No Do you have any skin irritations such as eczema? If yes, please indicate below where outbreaks occur. Yes No Do you have any seizure related conditions? Yes No Do you have a tendency to faint or become dizzy? Yes No Do you have prosthetic implants? Yes No Are you sensitive to petroleum-based products? Yes No Do you have a history of cancer? Yes No Are you undergoing radiation or chemotherapy? Yes No Do you have a pacemaker? Yes No Are you anaemic? Yes No Do you have a medical condition that has resulted the necessity for you to pre-medicate with an antibiotic prior to a dental or other invasive procedure? Yes No Do you have difficulties being anesthetised for dental procedures? Yes No Have you experienced a Mitral Valve Prolapse and/or do you have valve implants? Yes No Do you have a history of heart attack or stroke? Yes No Do you have any heart conditions? Yes No Are you allergic to hair dyes? Yes No Do you have high or low blood pressure? If yes, please note whether it s high or low below. Yes No Do you have any type of hepatitis? Yes No Do you have moles, freckles and/or any sort of abrasion or abnormal skin in or around the procedure area? Yes No Do you wear contact lenses? Contact lenses must be removed for eyeliner procedures! Yes No Do you use Latisse or any other eyelash growth product? Yes No Do you have glaucoma or any other eye disease? If yes, please explain below) Yes No Do you have dry eyes? Yes No Do you or have you suffered from fever blisters or cold sores (even if it was only once and a long time ago)? Yes No Do you regularly drink alcohol? Alcohol should be avoided at least 24-hours before the procedure. Yes No Do you regularly consume caffeinated beverages? Caffeine should be avoided the day of the procedure. Yes No Do you have any other medical conditions that may be relevant to this procedure? If yes, please share details below. Yes No Health History Specifics: Client Signature: Date:

3 Acknowledgements & Agreement By signing this agreement, I acknowledge that I have been given the full opportunity to ask any and all questions that I might have about Permanent Makeup Application (the Procedure ) and that all of my questions have been answered to my full satisfaction by the Artist, as named above, who will be performing the Procedure. I specifically acknowledge that I have been advised of the facts and matters set forth below. (initial) I am over the age of nineteen (19) and I have truthfully represented to the Artist that undergoing the Procedure is by my choice alone. (initial) I have answered the above health history form truthfully to the best of my knowledge. (initial) I understand that the Procedure is risky and I am having it done at my own risk. (initial) I am not pregnant or nursing. (initial) I am not under the influence of drugs or alcohol. (initial) I do not use blood thinners or any other medications that increase bleeding time. (initial) I do not have skin conditions such as acne, eczema, psoriasis or any other skin sensitiveness in the Procedure area. (initial) I do not currently have cancer. I am not undergoing chemotherapy and I have not undergone chemotherapy in the past 12 months. (initial) I do not have diabetes, keloid scarring, a history of hemophilia/abnormal bleeding, or any medical condition that might affect the healing of the Procedure area. (initial) I do not currently take Acutane or any other acne medication and I have not taken Acutane or any other acne medication for the past 12 months. (initial) I do not currently have any type of infection or rash anywhere on my body. (initial) I do not have freckles, moles or sunburn in the Procedure area. (initial) I consent to have the Artist perform the Procedure and also any actions or conduct that are reasonably necessary to perform the Procedure. (initial) Discomfort is usually mild, however each person s tolerances are different. I consent to the application of topical anesthetic to manage my discomfort. (initial) I do not have any sensitivity to dyes or local anesthetics (for example; Lidocaine or Tetracaine) or Epinephrine. (initial) I have received the aftercare instructions and I agree to follow them. I also agree that if I do not follow the instructions, any touchup needed will be done at my own expense. I acknowledge that: (initial) I might have an allergic reaction to the pigments, or anesthetic numbing cream used in the Procedure and I accept the risk that such a reaction is possible. (initial) Swelling in the Procedure area is minimal to moderate and usually subsides within a few days. (initial) Bruising may occur and, if so, usually resolves within a few days. Bruising that lasts more than a week is very uncommon. (initial) Infection and/or complication is always possible as a result of the Procedure, particularly in the event that I do not take proper care of the area following the Procedure. Should signs of an infection occur, I will seek appropriate care from my primary physician or another registered healthcare provider. (initial) Variations in color exist between the color selected and how it will ultimately look when my Procedure area has healed. I also realize that the Procedure area will be dark for approximately the first six (6) days and will lighten thereafter. (initial) All color fades. This is a fact that applies to pigments/inks used for cosmetic tattooing. Activities that may reduce longevity of the pigment include intentional sun exposure and/or the use of strong chemicals on the procedure area. Color refresh appointments will be necessary in the future. The time frame cannot be predicted, as this is very client specific. A fee will be charged for the color refresh appointment. (initial) The final result will not be obtained without a touch up visit to reshape or augment the Procedure area(s). This is usually done no sooner than six (6) weeks after the initial visit. (initial) The final appearance of the Procedure area will be achieved six to eight (6-8) weeks after the final visit. (initial) The Procedure will result in a permanent change to my appearance and no representation has been made to me as the ability to later change or remove the results. (initial) Hyper-pigmentation and hypo-pigmentation, or scarring is a possibility as a result of my body s reaction to the skin being broken during the procedure. I realize that my body is unique and that my Artist cannot predict how my skin may react as a result of this procedure. (initial) Tattoos may cause MRI (Magnetic Resonance Imaging) artifacts and there may be warming and/or tingling sensation in the Procedure area during an MRI due to the iron oxide (metallic salts) contained in some pigments. I understand that I should advise my physician that I have permanent makeup (a tattoo) in the event that I require an MRI. (initial) Cosmetic tattooing is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the procedure. (initial) The Herpes Simplex Virus type 1 (HSV-1) (fever blisters or cold sores) may occur as a result of a lip Procedure. The anticipation of an outbreak may be pretreated with antiviral medications, available by prescription from a primary physician. (initial) The eyeliner Procedure cannot be conducted while I am wearing eyelash extensions. (initial) Future skin treatments such as laser hair removal, plastic surgery or other skin altering Procedures may result in adverse changes to the Procedure area.

4 Liability The Client acknowledges that the Artist will take all necessary precautions to protect the Client during the Procedure and that the Artist is not a medical professional even if they carry a secondary designation as a registered massage therapist (RMT). The Procedure is not within the scope of practice of a RMT. The Artist shall not be liable for any direct, indirect, special, consequential, or exemplary damages or injury to the Client resulting from, or in any way connecting to the Procedure. Risks The Client acknowledges and assumes all risks inherent or in any way relating to the Procedure and agrees to take all necessary precautions to protect the Client from all damage and injury that could arise from the Procedure. The Client is fully aware that the Procedure is inherently dangerous and that such Procedure is subject to mishap, injury and possibly even death. The Client acknowledges that no warranties, either express or implied, have been given concerning the safety of the Procedure or the skills of the Artist. Release The Client hereby releases the Artist, its principals, agents, and employees, from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, which the Client now has or which hereinafter may have, against the Artist by reason of or in any way related to the Procedure. The Client agrees to indemnify and hold harmless the Artist, its principals, agents, and employees from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, resulting from, or in any way connected to, the Procedure. Care and Maintenance I agree to follow the care and maintenance instructions provided by the Artist for the care of the Procedure area following the Procedure, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that failure to follow aftercare instructions may result in permanent damage to my skin, scarring and may prevent the pigment from settling. I agree to keep the Procedure area clean and to follow aftercare instructions. No Known Medical Conditions / Informed Consent I have read and completed the Procedure Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as keloid scarring, or infection) that the Procedure may cause to those who have specific medical or skin conditions. I understand that in rare cases persons may be allergic or have hypersensitivity to some of the products used during the Procedure. I understand that allergies to pigments may develop at any time after the Procedure, while the pigment is implanted in my skin. I further state that I have no known medical condition that might be aggravated by the Procedure or any medical condition that would prevent me from complying with or heeding to the Artist s instructions or these warnings. Spot Test I understand, that should I have any concerns about any possible reaction to the chemicals and products used, I may arrange at my own discretion to book an advance spot test where topical anaesthetics and pigment will be applied to my skin externally, hours prior to the time in which I m scheduled for the Procedure. I understand that the test result is not viewed by a medical professional unless I make arrangements to have this done myself. I also understand that spot testing does not guarantee that no future sensitivity or reactions will develop. I agree that scheduling a spot test shall be my own responsibility and at my sole discretion, and have absolutely no bearing on the contents or signing of this Agreement or any clauses contained therein.

5 Cancellation Policy I understand that the appointment time is reserved for the Client. A late cancellation or missed visit leaves a hole in the Artist's day that could have been filled by another client. The Artist requires 24 hours notice for any cancellations or changes to your appointment. Clients that provide less than 24 hours notice or miss their appointment will be charged a cancellation fee of the entire cost of the appointment as booked. If the Client arrives late for their appointment, no additional time will be added to the appointment. The Procedure will be stopped at the scheduled end time of the appointment, regardless as to whether or not the desired outcome is achieved in the remaining amount of time. The client will be charged in full for the service time as booked. Permissions to Use Photographs I hereby grant the Artist the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyebrows, both before and after this Procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary by the Artist. I further expressly assign any copyright in these photographs to the Artist. I also grant my consent for the Artist to use my image and likeness as contained in these photographs for any advertising or other purposes. Children I understand that the Procedure requires the full attention of the Client and the Artist. As such, unattended minor children are not permitted in the Procedure space during your appointment. Fees & Refunds The fee for the Procedure has been explained to me and has been agreed upon. I understand that the total fee for services rendered is due upon completion of the initial procedure(s) and that there will be separate fees for any future modification of the design(s) or major color changes. I understand that the Procedure and all services rendered by the Artist are non-refundable. Design Approval I approve of the brow shape/design created by the Artist and the colors of pigment selected, and have been given an opportunity to modify the brow shape/design created by the Artist and the color of pigment selected prior to application. Declaration The Client has read this entire document, understands its contents, and knows the truthfulness thereof. IN WITNESS WHEREOF the parties have signed, sealed and delivered this Agreement as of the date first above written. Client Signature: Artist Signature: Printed Name: Printed Name: Chrystal Ladouceur Date: Date:

6 Subsequent Visit Record By signing the below I confirm that I have reviewed, agreed to, and updated the details contained within this form as necessary for today s appointment. Visit No. Date Procedure Client Signature Artist Signature Significant Updates and/or Changes to Intake Form Date Change