VENUS BEAUTY LOUNGE. Before Your Microblading Session

Size: px
Start display at page:

Download "VENUS BEAUTY LOUNGE. Before Your Microblading Session"

Transcription

1 Great microblading is not a beautiful result directly after treatment. It is a crisp, natural, long-lasting result once healed. Aleksandra Maniuse-Founder Deluxe Brows Microblading is a manual technique of hyper-realistic eyebrow drawing using a single use, sterile and disposable tool which consists of very fine pins. The tool is dipped into pigment, then a hair shape is scratched/implanted into the skin to the basal layer of the dermis. It is a form of tattooing. The shape of the brow is based on facial morphology and the Golden Proportion (phi 1.618). Before Your Microblading Session These products cause bleeding, making it difficult to implant pigment which will effect pigment retention: NO Aspirin, Niacin, Vitamin E or Ibuprofen 24 hours before. Fish oil, krill oil and even garlic can cause bleeding-avoid before your session. NO caffeine, alcohol or energy drinks on the day of the session. Do not tan or have a sunburn. Do not tweeze, wax or tint 3 days before. Do not work out the day of your session. Confirm you have had lidocaine before (like in dental work or skin biopsy). Confirm metal allergy with patch test or waive patch test. No chemical peels, microdermabrasion or other intense treatments before permanent makeup procedure. Causes skin irritation and faster cell rejuvenation, which can cause pigment loss. Botox injection-microblading first, then botox after 1 month. If botox is done already wait 1 month. Please note-you will be more sensitive around your menstrual cycle. Avoid scheduling before or during your cycle-you will be very uncomfortable! Page 1 of 5

2 The Main Pigment Fading Factors 1. Weak after care the scab will appear and pigment will fall off with the scab 2. Oily skin type / young skin / metabolism / big pores 3. Scars 4. Mechanical or chemical treatment (peels, dermabrasion, mesotherapy, laser) 5. Improper depth 6. Glycol, retinol products or/and treatments 7. Amount of melanin in the skin After Care Instructions There are a range of aftercare options and approaches-permanent makeup artists have many preferences. I have seen the best results from the following method: 1. The day of your treatment: wash your brow 3 to 5 times with a gentle cleanser followed by a thin application of salve (provided to you). This removes lymph which causes scabbing. 2. The day after your treatment: simply apply a thin layer of salve to your brows 3-5 times per day. Oily skin types can do less, dry skin types should do more. Avoid getting them wet! For the first 7 days following your microblading service: NO makeup, creams, lotions, ointments, etc. on your brows. Except for your healing salve! NO sauna, pools, steam, sunbathing, lakes, etc. Do not be alarmed if you see pigment on the gauze, as this is excess pigment and/or body fluid that is naturally exiting your skin. In case of itching, Bactine can be used, which contains lidocaine and benzalkonium chloride. It will also disinfect the area. Do not use any other ointments or creams with vitamins on eyebrows. Do not rub, pick or scratch the treated area. Let any scabbing or dry skin naturally exfoliate off. Picking can cause scarring. Avoid heavy sweating for the first 7 days. Do not apply creams containing glycolic acid or Retin-A to face or neck for 10 days. No facials, botox, chemical treatments and microdermabrasion for four weeks. Avoid sleeping on your face for the first 7 days. Eyebrows will appear darker and bolder due to natural scabbing and healing for the first 10 days. Healing of deeper strokes might last between days. Drinking alcohol in excess can lead to slower healing time. Wear sunglasses and sunscreen (after 7 days) to protect your permanent makeup and prevent fading from the sun. Page 2 of 5

3 1. The day after: When your new brows are completed, they will appear too dark. This is temporary. You are seeing pigment in both layers of your skin (epidermis and dermis). The top layer of your skin sheds and renews itself every few days and with this natural process the pigment in the top layer will peel off. This initial dark look will not last. Only the color in the dermis (second layer of skin) will be long lasting. If you are happy with your new permanent cosmetic color and darkness when you leave your first session, then you will be unhappy within one to three weeks. For this reason, it is important for you to be patient and let your skin heal. 2. Permanent makeup is a layering process of carefully implanting microscopic colors into the dermis. In cases of camouflaging scars and corrective makeup the goal can only be achieved through repeated applications and refinements to the previous applications after healing. I would always rather apply LESS than TOO MUCH. Generally eyebrows lose 10-20% of their original color after healing. 3. Touch-up visit: ONLY AFTER 6 WEEKS! Your skin needs time to heal completely before another microblading treatment. The goal of this visit is to fill in any areas that need enhancement or address areas that have healed with a loss of pigment. Every person is unique and I cannot predict how your makeup will heal-variables include: proper after care, age of client, condition of skin, products client uses, sun exposure, permanent facials/peels, etc. If you have any unexpected problems with the healing of the skin, please contact Susan Ruoff immediately to discuss further instructions. (231) Not everyone heals the same way or in the same time frame. This is a general timeline: Day 1: I love my new brows! Days 2-4: I don t like this color, it s too dark. Days 5-7: Oh no! My brows are peeling! Days 8-10:?!?!? My brows are gone!! Days 14-28: Thank goodness my brows are coming back-still looking patchy and uneven. Day 42: After touch up-they are beautiful! Consent and Release Agreement for Microblading (Eyebrow Tattoo) Date: Name: Age/Date of Birth: Minors with parental consent only. Address: City/Zip Phone: Referred by: Fee: Microblading can last anywhere from 6 months to 3 years based on skin type, skin age, skin quality, sun exposure, skin care products used, skin care treatments done, proper aftercare, etc. Your color refresh appoint at this time will be approximately $ Skin Type: Normal Combination Dry Oily Skin Texture: Thick Normal/Healthy Thin Extremely Delicate Pigment Colors Used: Notes: Page 3 of 5

4 Although Microblading is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure. Generally, the results are excellent, however, a perfect result is not a realistic expectation. It is usual and advised to expect a Touch-up after healing is completed-this is included in the fee. Health Concerns In order to perform the eyebrow tattoo procedure in a safe manner, please read the following health concerns carefully: The contraindications are not only for your well-being and safety, but mine as well. Venus Beauty Inc. assumes no liability in case of false information or lack of disclosure. Microblading is NOT recommended for the following clients who are or have: PLEASE INITIAL YES NO Diabetes or other conditions which may affect blood circulation and/or ability to fight infection. YES NO History of epilepsy, seizures, fainting or narcolepsy. YES NO Pacemaker or major heart problems. YES NO History of hemophilia or excessive bleeding. YES NO Viral infections and/or diseases or active breakout (herpes, HIV/AIDS, hepatitis.) YES NO Rosacea YES NO Keloids YES NO Organ transplant YES NO Pregnant/nursing YES NO Undergoing chemotherapy YES NO Treatment with anticoagulants or other medications that thin the blood or prevent clotting. YES NO History of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals or other sensitivities related to body art procedures. YES NO Cortisone Shots or Steroid Use Any client reporting one or more of the above conditions should be encouraged to consult their physician before undergoing a permanent makeup procedure. Please list all medications you take on a regular basis: Other contraindications: any skin irritations on the brow area (Psoriasis, rashes, sunburn, frostbite, acne), right after waxing (after 3 days allowed), after strong chemical peels, Botox (after 1 month allowed.) Using Accutane, Isotretinoin (Retin-A) or other strong retinoid (after 6 months allowed), moles and other skin appendages. If you are sick (cold, flu, strep, etc.) very thin/sensitive and low pain tolerance. CLIENT HAS READ AND UNDERSTANDS THE FOLLOWING RISKS: CLIENT INITIAL EACH PLEASE Despite the application of the most advanced and top quality pigments, allergic reaction is possible but rare. The client is informed about this and she/he assumes liability Small scabs may occur after the first treatment (depending on the skin structure) which can cause a loss of pigment and/or change in color intensity, thus one or more additional treatments may be necessary In the first 7 days eyebrows are up to 20% darker and 10-15% thicker. How color appears depends on the natural skin pigment The pigment is absorbed differently due to variations in skin quality, thus there is no warranty for treatment success The eyebrow shape is determined according to the face proportions Page 4 of 5

5 I HAVE had lidocaine before and HAVE NOT had a reaction (tooth repair/skin procedures) The minimum or maximum duration of microblading procedure cannot be determined with certainty, nor can a warranty be given on performed treatment The first touch up is done six weeks after the treatment. For oily skin it may be necessary to perform more corrections. Any touch up fees may apply for future appointments if touch ups are desired Permanent makeup always leads to skin injury. Therefore, it is important to carefully and gently nurture your skin after the treatment to allow healing without complications. Inadequate care in the healing phase of the skin can lead to poor results and Venus Beauty Inc. cannot be liable for it Permanent makeup is an art and not a science. Client s results will vary and using a makeup pencil or brow powder may still be needed after treatment If you have metal allergy you must have a 24 hour patch test!!!! You may waive a patch test, however, your reaction to pigment may be detrimental to your brow treatment and results. NO METAL ALLERGY YES METAL ALLERGY 24 HOUR PATCH TEST 24 HOUR PATCH TEST WAIVED I confirm that I have read and understood the above information All of my questions have been answered to my satisfaction The treatment procedure and post-treatment care were explained to me in detail and I agree with it After care instructions & supplies were given to me to take home VENUS BEAUTY LOUNGE is a licensed body art facility by the State of Michigan. Susan Ruoff is a licensed permanent make-up/tattoo artist by the State of Michigan. Susan Ruoff completed Deluxe Brows (September 2016) fundamental microblading training and completed Phi Brows fundamental microblading training (May 1 st, 2018). Client Print Name: Client Signature: Photography Release Consent I would like your permission to use photos of your brows (before and after) for my portfolio, social media, print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not. YES, feel free to use them NO, please do not use them Signed Special requests, concerns or remarks for Susan Ruoff: Page 5 of 5

Microblading. More information can be found at the Society of Permanent Cosmetic Professionals.

Microblading. More information can be found at  the Society of Permanent Cosmetic Professionals. Microblading (eyebrow tattooing, eyebrow embroidery, microstroking, micropigmentation, dermal implantation, permanent cosmetics, feathering eyebrows cosmetic tattooing) Any time color is placed into the

More information

VICKI HENKE MICROBLADING PERMANENT COSMETICS. What to expect in the healing process for all brow enhancement/permanent makeup procedures.

VICKI HENKE MICROBLADING PERMANENT COSMETICS. What to expect in the healing process for all brow enhancement/permanent makeup procedures. MICROBLADING/MANUAL PERMANENT MAKEUP TREATMENT BEFORE & AFTER CARE INSTURCTIONS What to expect in the healing process for all brow enhancement/permanent makeup procedures. WHILE YOUR SKIN HEALS, BE PREPARED

More information

Microblading Consent and Release Agreement

Microblading Consent and Release Agreement Microblading Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a Microblading semi-permanent make up application. If

More information

Contraindications Pre and Post Instructions

Contraindications Pre and Post Instructions Contraindications Pre and Post Instructions **VERY IMPORTANT---PLEASE READ** **It is very important you follow these rules as medical conditions can affect the outcome of your eyebrows. Please notify me

More information

Client Medical History Form

Client Medical History Form Client Medical History Form Today s Date: Birthday: / / Age Name: TXID# Address: Phone: Email: Tattoo Area: Eye Brows (Micro-Blading) Brand of Ink: Bio Touch Pure / / / Emergency Contact: Phone: Do you

More information

Microblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address

Microblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address Microblading Consent Form Client Medical History: Date Birthdate Age Name Form of Id # Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES

More information

Client Medical History Form

Client Medical History Form Client Medical History Form Date Birthdate Name Address Phone Email Emergency Contact Person Phone Do you have or previously had any of the following: (Circle YES or NO) YES NO History of MRSA YES NO Botox

More information

Client Medical History Form

Client Medical History Form Client Medical History Form Date Birth Date Age DL or ID# Name: Address City State Zip Phone Email Emergency contact person Phone Do you presently have or previously had any of the following: (Circle yes

More information

Consent and Release Agreement

Consent and Release Agreement Consent and Release Agreement This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery Semi-permanent make up application. If you

More information

STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines. Signed

STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines. Signed STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow

More information

Permanent Cosmetics Contraindications

Permanent Cosmetics Contraindications Permanent Cosmetics Contraindications under 18 years of age diabetes pregnant or lactating women glaucoma skin diseases such as psoriasis, eczema and undiagnosed rashes or blisters on the site that is

More information

Touch Up-Color Refresh Policy

Touch Up-Color Refresh Policy 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.

More information

Micropigmentation (Semi-Permanent Makeup) Informed Consent

Micropigmentation (Semi-Permanent Makeup) Informed Consent Micropigmentation (Semi-Permanent Makeup) Informed Consent The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent

More information

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Age Have you received chemotherapy

More information

IF YOU GET FILLERS, THEY SHOULD BE DONE 6 WEEKS PRIOR TO YOUR SCHEDULED PROCEDURE OR DONE 6 WEEKS AFTER THE PROCEDURE.

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,

More information

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy

More information

Informed Consent for Light Energy Tattoo Removal

Informed Consent for Light Energy Tattoo Removal Dr. Joseph G. Protain 813 Kentwood Dr. Boardman, OH 44512 (330)953-3515 Informed Consent for Light Energy Tattoo Removal Customer s name: Date: I, consent to and authorize and members of his/her staff

More information

513 Maple Ave West, Vienna, VA

513 Maple Ave West, Vienna, VA CLIENT INFORMATION AND CONSENT FORM: SKIN CARE Name Date of Consultation Address City State Zip Home phone ( ) Cellular phone ( ) E-mail Date of birth Emergency contact and telephone number How did you

More information

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING Name: DOB: Phone : Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy or radiation

More information

Permanent Makeup Before & Aftercare Instructions. Permanent Makeup by Michelle Louise

Permanent Makeup Before & Aftercare Instructions. Permanent Makeup by Michelle Louise Permanent Makeup by Michelle Louise Permanent Makeup Before & Aftercare Instructions IMPORTANT INFORMATION This document contains important information. Please read it carefully. www.michelle-lousie.com

More information

Date: Date of Birth: Gender: Male Female. City: State: Zip: Caucasion a African-American Hispanic Asian East Indian American Indian

Date: Date of Birth: Gender: Male Female. City: State: Zip: Caucasion a African-American Hispanic Asian East Indian American Indian Contact Information: Date: Date of Birth: Gender: Male Female Name: Address: City: State: Zip: Home Phone: Work/Day Phone: Cell: Email: Emergency Contact: Emergency Contact Phone: Medical Background Ethnic

More information

Informed Consent For Facial Rejuvenation/Collagen Remodel

Informed Consent For Facial Rejuvenation/Collagen Remodel Informed Consent For Facial Rejuvenation/Collagen Remodel Client s name: Date: I authorize SilkySkin Laser Centers to perform the laser procedure. You will be treated with the Cynosure Elite TM laser,

More information

Maya Med Spa 6330 Broadway Blvd. Suite B, Garland, TX Name: Date of birth: Address: Pharmacy of your choice:

Maya Med Spa 6330 Broadway Blvd. Suite B, Garland, TX Name: Date of birth: Address: Pharmacy of your choice: Client Consultation Name: Date of birth: Address: Home Phone: Cell Phone: Business Phone: E-mail address: Married: Yes No If yes, anniversary date: Employer: Occupation: Pharmacy of your choice: Does your

More information

HEALTH HISTORY INFORMATION

HEALTH HISTORY INFORMATION HEALTH HISTORY INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:

More information

Medication Name Reason Taken Dosage Last Date Taken

Medication Name Reason Taken Dosage Last Date Taken CLIENT HISTORY FORM Print Name Location of Service: Email Birth Date Age Gender @ Female Address City State / Male Emergency Contact Name and Number Home Phone ( ) Cell Phone ( ) Today s Procedure Description:

More information

ibrow Studio Client Information Packet

ibrow Studio Client Information Packet ibrow Studio Client Information Packet Thank you so much for trusting me with your beautiful face! Prior to booking an appointment, we ask that all ibrow Studio clients read and review the information

More information

Client Intake Form. Name: Date: Address: City: ST: Zip: Phone:

Client Intake Form. Name: Date: Address: City: ST: Zip:   Phone: Client Intake Form Name: Date: Last First Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current

More information

INFORMED CHEMICAL PEEL CONSENT. 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands.

INFORMED CHEMICAL PEEL CONSENT. 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands. INFORMED CHEMICAL PEEL CONSENT 1. I authorize the chemical peel listed above, to my face and / or neck, chest and hands. 2. Depending on the chemical peel site, there may be redness and/or irritation and

More information

Brow and Beauty Bar - Permanent Makeup

Brow and Beauty Bar - Permanent Makeup General Consent and Procedure Permit Clients Full Name Mr/Mrs/Miss/Ms Address e-mail I hereby authorize Erin Exline to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises

More information

IPL CONSULTATION AND LIABILITY DOCUMENTATION

IPL CONSULTATION AND LIABILITY DOCUMENTATION Name...... Address:... Date of Birth:... Suburb:... Postcode:... Home Phone:... Mobile:... Email Address:... How did you hear about us?... Contact in case of emergency:... Place a tick in the areas of

More information

Patient Contact Information. Name. Home Address. City State Zip

Patient Contact Information. Name. Home Address. City State Zip Patient Contact Information Name Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Date of Birth Emergency Contact Name and Phone Who Referred You To This Clinic? Would you like to receive

More information

Would you like to receive informational updates, specials and newsletters? Yes No

Would you like to receive informational updates, specials and newsletters? Yes No Patient Contact Information Name Home Phone Work Phone Cell Phone Home Address City State Zip E-Mail Date of Birth Emergency Contact Name and Phone Who Referred You To This Clinic? Would you like to receive

More information

APPOINTMENT POLICY. Dear Client, Your time is very important to me and I appreciate that you equally respect mine. Below is our appointment policy.

APPOINTMENT POLICY. Dear Client, Your time is very important to me and I appreciate that you equally respect mine. Below is our appointment policy. APPOINTMENT POLICY Dear Client, Your time is very important to me and I appreciate that you equally respect mine. Below is our appointment policy. 1. One consultation visit is free of charge. A 24 hour

More information

Pre-Treatment Advice and Procedures

Pre-Treatment Advice and Procedures 1 Client copy Pre-Treatment Advice and Procedures Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear "crusty"

More information

CLIENT HISTORY. May we contact you at these numbers?

CLIENT HISTORY. May we contact you at these numbers? CLIENT HISTORY Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Street City State Zip Business Phone: May we contact you at these numbers? Other ID: Referred by: Emergency Contact:

More information

CLEAR TOE INTAKE INFORMATION

CLEAR TOE INTAKE INFORMATION CLEAR TOE INTAKE INFORMATION Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: Female Male Home Phone: Cell Phone: Leave messages at: Home Cell Other: Email address:

More information

Pre Treatment Advice and Procedures

Pre Treatment Advice and Procedures Pre Treatment Advice and Procedures 1. Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up

More information

Hair To Bare South. Client Name: Date:

Hair To Bare South. Client Name: Date: Hair To Bare South Client Name: Date: I authorize Rachelle Stokes (Hair To Bare South) to perform the treatments. The purpose of these treatments is to diminish or remove unwanted hair. The quantity of

More information

Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine

Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine MedSpa 1064 Suites at Somerset Square 140 Glastonbury Blvd. Glastonbury, CT 06033 860.657.1064 Welcome to Medspa 1064, Connecticut s Premier Center for Cosmetic Laser Medicine This form is to introduce

More information

Forename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM

Forename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM Forename Surname... SOPRANO ICE SHR LASER CONSULTATION FORM 1 SOPRANO ICE SHR PERSONAL INFORMATION Gender: Male/Female Date of birth.age. Home address..postcode.. Telephone..Mobile.. Email address.. GP

More information

APPLICANT/BODY ART ESTABLISHMENT PERMIT STATEMENT OF CONSENT

APPLICANT/BODY ART ESTABLISHMENT PERMIT STATEMENT OF CONSENT 9. Provide the Following With Application: A. (New & Renewal Applications) Present original and provide copy of Business Certificate issued by the Everett City Clerk under provisions ofmgl c. 110 subsection

More information

Pre-Treatment Advice and Procedures

Pre-Treatment Advice and Procedures Pre-Treatment Advice and Procedures 1) Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear crusty for up

More information

Permanent Makeup Intake Form

Permanent Makeup Intake Form 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 Email Mobile Phone Address

More information

Client Questionnaire Skin & Health

Client Questionnaire Skin & Health Client Questionnaire Skin & Health Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle and skin care concerns; thereby

More information

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP

CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR PERMANENT MAKEUP Name: DOB: Best Phone Contact: Address: Email: List any medications you have been taking in the past 6 months: Have you received chemotherapy

More information

East Hill Medical Group

East Hill Medical Group Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):

More information

AREA OF BODY TATTOO IS SITUATED?

AREA OF BODY TATTOO IS SITUATED? CLIENT CONSULTATION LASER TATTOO REMOVAL FORM Address: Date of Birth: Suburb: State: Postcode: Telephone: Work: Mobile Home: Other: Email Address: How did you hear about us? Tattoo Removal Colours in tattoo

More information

NEW CLIENT GENERAL INFORMATION FORM

NEW CLIENT GENERAL INFORMATION FORM NEW CLIENT GENERAL INFORMATION FORM First Name: Last Name: Email: Date of Birth: Occupation: Home Phone: Cell Phone: Carrier: Gender: Female Male Preferred Staff Gender: Female Male Preferred Staff Member:

More information

Personal Profile and Health History

Personal Profile and Health History --CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What

More information

5504 Backlick Road Springfield, Virginia

5504 Backlick Road Springfield, Virginia Name: Address: Phone: City: Zip Code: Cell: Phone: Text Cell Phone email How did you hear about us: General Health State: Contact me by 1. Rate your level of stress: (5 = highest, 1= lowest) 5 4 3 2 1

More information

Address City State ( ) 32 YES NO. 33 YES NO Are you undergoing radiation or chemo-therapy treatment? 39 YES NO 45 YES NO

Address City State ( ) 32 YES NO. 33 YES NO Are you undergoing radiation or chemo-therapy treatment? 39 YES NO 45 YES NO CLIENT HISTORY FORM Print Name Location of Service: Email @ Birth Date Age Gender Female Address City State / Male Emergency Contact Name Home Phone ( ) Cell Phone ( ) Today s Procedure Description: Eyebrows

More information

GENERAL CONSENT AND PROCEDURE PERMIT FORM

GENERAL CONSENT AND PROCEDURE PERMIT FORM GENERAL CONSENT AND PROCEDURE PERMIT FORM Please read this form fully and sign at the end. If you are unsure about a particular detail of the form, please speak to your therapist. If unforeseen condition

More information

PIERCING CONSENT RELEASE FORM PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT

PIERCING CONSENT RELEASE FORM PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT PIERCING CONSENT RELEASE FORM PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT In consideration of receiving piercing from (Name of Practitioner)

More information

Brilliant Bodywork. Name: Date: Address: City: State: Zip: Home Phone: Business Phone: Cell Phone: Date of Birth: address:

Brilliant Bodywork. Name: Date: Address: City: State: Zip: Home Phone: Business Phone: Cell Phone: Date of Birth:  address: Brilliant Bodywork Skin Care History Questionnaire and Waiver Please answer the following questions so that your Skin Care Specialist may have a better understanding of your general health and lifestyle,

More information

PRODUCT YES / NO BRAND NAME PRODUCT NAME FREQUENCY OF USE

PRODUCT YES / NO BRAND NAME PRODUCT NAME FREQUENCY OF USE Consultation Form Today s Date: Name: Your Birthday: Spouses Name: Spouses Birthday: Anniversary: Address: City: St: Zip Home Phone: Office Phone: Cell Phone: Email Address: Purpose for visit: How did

More information

COSMETIC LASER AND AESTHETICS CENTER

COSMETIC LASER AND AESTHETICS CENTER COSMETIC LASER AND AESTHETICS CENTER PERSONAL INFORMATION Please complete the following: Date: Name: Date of Birth: Home Address: City: State: Zip: Home Telephone: ( ) Cell: ( ) Work Phone: ( ) Email This

More information

Client Information & Health History

Client Information & Health History Client Information & Health History Name: Address: City: State: Zip Code: Cell#: Work#: Home#: Email: Preferred method of contact: email cell# work# home# Date of Birth: Occupation: How did you hear about

More information

Consultation Form: Coffeeberry Peel

Consultation Form: Coffeeberry Peel Consultation Form: Coffeeberry Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible advice

More information

3-DAY INTENSIVE MICROBLADING COURSE. Maja Lipovec & Bojan Jončič INTERNATIONAL MICROBLADING TRAINNING TEAM

3-DAY INTENSIVE MICROBLADING COURSE. Maja Lipovec & Bojan Jončič INTERNATIONAL MICROBLADING TRAINNING TEAM 3-DAY INTENSIVE MICROBLADING COURSE Maja Lipovec & Bojan Jončič INTERNATIONAL MICROBLADING TRAINNING TEAM About this course Microblading is also refered to as eyebrow tattoos, eyebrow feathering or embroidery

More information

Breakout Session B: The Facts and Myths of Microblading. Rose Marie Beauchemin

Breakout Session B: The Facts and Myths of Microblading. Rose Marie Beauchemin 24TH Annual Meeting Breakout Session B: The Facts and Myths of Microblading Rose Marie Beauchemin Upon completion of this presentation, the participants will self-report an increase in knowledge about:

More information

MICROFEATHERING. Photo by Robin Black

MICROFEATHERING. Photo by Robin Black Photo by Robin Black Microfeathering is Kristie s signature Microblading Concept and is performed by depositing pigment superficially into the epidermis of the eyebrow. After numbing the area with a topical

More information

CLIENT QUESTIONNAIRE

CLIENT QUESTIONNAIRE CLIENT QUESTIONNAIRE YOUR INFORMATION Name Age DOB Address City State Zip Home Phone Cell Phone Email MEDICATIONS Medication When How Long Medication When How Long Antibiotics Androstendione Accutane Testosterone

More information

Laser Skin Resurfacing what to expect

Laser Skin Resurfacing what to expect Laser Skin Resurfacing what to expect Laser skin resurfacing is a treatment to reduce facial wrinkles and skin irregularities, such as blemishes or acne scars. The technique directs short, concentrated

More information

HEALTH HISTORY. Name Date DOB Age. Home Phone Work Mobile Other

HEALTH HISTORY. Name Date DOB Age. Home Phone Work Mobile Other HEALTH HISTORY To ensure both the effectiveness and the safety of your treatment, please complete this health history as accurately as you can. PERSONAL INFORMATION Name _ Date DOB Age Address _ City State

More information

GENERAL CONSENT FORM

GENERAL CONSENT FORM GENERAL CONSENT FORM Please read this form fully, initial each line item and sign at the end. If you are unsure about a detail of the form, please speak to your practitioner. If unforeseen conditions arise

More information

(Injection of collagen, hyaluronic acid or other filler materials) INFORMED CONSENT FOR DERMAL FILLER

(Injection of collagen, hyaluronic acid or other filler materials) INFORMED CONSENT FOR DERMAL FILLER INFORMED CONSENT FOR DERMAL FILLER (Injection of collagen, hyaluronic acid or other filler materials) INTRODUCTION Dermal fillers are injected just under the skin s surface in order to temporarily correct

More information

Consultation Form: AHA Chemical Peel

Consultation Form: AHA Chemical Peel Consultation Form: AHA Chemical Peel NAME: ADDRESS: TELEPHONE NUMBER: DATE OF BIRTH: EMERGENCY CONTACT: EMAIL ADDRESS: OCCUPATION: DOCTORS NAME/SURGERY: We aim to ensure clients have the best possible

More information

Massey Medical. Medical History (Dermal Filler) MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox:

Massey Medical. Medical History (Dermal Filler) MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox: Medical History (Dermal Filler) Name: Date: _ Date of Birth: Phone: _ MEDICAL INFORMATION: I am interested in the following services: Juvederm: Botox: NO YES Allergies history of severe allergy or anaphylaxis.

More information

NEW CLIENT FORM. Address: City: State: Zip: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type seems to best describe your skin

NEW CLIENT FORM. Address: City: State: Zip: FITZPATRICK CLASSIFICATION SYSTEM: Please select the skin type seems to best describe your skin OREGON LASER & WELLNESS CENTER 4370 SE KING ROAD SUITE 105 MILWAUKIE, OR 97222 PHONE: 503 305 7704 or 971 263 7679 Date: Name: NEW CLIENT FORM Address: City: State: Zip: Email: Home Phone: Work Phone:

More information

Chameleon Medical Spa NEW CLIENT HISTORY

Chameleon Medical Spa NEW CLIENT HISTORY NEW CLIENT HISTORY This information will allow your professional skincare specialist to provide the optimum products and services. First Name: Last Name: Date: Birth date: Address: City: State:_ Zip code:

More information

Thinking of Permanent Cosmetics?

Thinking of Permanent Cosmetics? Thinking of Permanent Cosmetics? Here are guidelines to help you have a great experience. People from all walks of life enjoy the benefits of permanent makeup. Professional women, athletes, those with

More information

Welcome to Bella! Give the Gift of Bella. A few tips to prepare you for your first visit: Gift Certificates are just $100 for a $150 value!

Welcome to Bella! Give the Gift of Bella. A few tips to prepare you for your first visit: Gift Certificates are just $100 for a $150 value! Welcome to Bella! We are glad to have you as our guest. We encourage you to visit our website to see all of the exciting new laser and skincare treatments that we offer. Please be aware of our 24 hour

More information

SALIBIAN MOSSI. Name Last First Middle. Address Apt. City State Zip. Home Phone Cell Phone Work Phone. Address

SALIBIAN MOSSI. Name Last First Middle. Address Apt. City State Zip. Home Phone Cell Phone Work Phone.  Address Name Last First Middle Address Apt. City State Zip Home Phone Cell Phone Work Phone Email Address Age Date of Birth Sex Height Weight Marital Status Drivers License # Social Security # Employer Occupation

More information

Timeless Makeup, LLC

Timeless Makeup, LLC Timeless Makeup, LLC CLIENT REGISTRATION (Please complete all blanks) I. CLIENT INFORMATION Name Date Address City Zip Phone number Email address Type of work Ethnicity Date of birth What was your hair

More information

Eyelash Extension History & Consent Form

Eyelash Extension History & Consent Form Eyelash Extension History & Consent Form Client Name: Date: Address: City: State: Zip: Home #: Business #: Cell #: Email: How may we contact you regarding scheduled appointments or specials? Check all

More information

Dermabrasion. Dermabrasion can decrease the appearance of wrinkles. It can also improve the look of scars, such as those caused by surgery or acne.

Dermabrasion. Dermabrasion can decrease the appearance of wrinkles. It can also improve the look of scars, such as those caused by surgery or acne. Dermabrasion Introduction Dermabrasion is a procedure that resurfaces a person s skin. A health care provider uses a device known as a dermabrader to quickly sand away the outer layers of skin. After dermabrasion,

More information

COLORADO AESTHETIC CENTER

COLORADO AESTHETIC CENTER COLORADO AESTHETIC CENTER 9320 Grand Cordera Parkway, Suite #250 Colorado Springs, CO 719.387.7800 Skin and Health Questionnaire Please answer the following questions thoroughly, as this provides a better

More information

Beautiful You LLC. Laser Hair Removal Pre/Post Treatment Care

Beautiful You LLC. Laser Hair Removal Pre/Post Treatment Care Beautiful You LLC Laser Hair Removal Pre/Post Treatment Care Pre-Treatment Instructions Avoid deep tanning, including tanning beds and tanning creams, 2 weeks before and 1 week after treatment. If you

More information

Laser Hair Removal. Name Date of Birth. Address City State Zip. Home Tel. # Cell # How Referred

Laser Hair Removal. Name Date of Birth. Address City State Zip. Home Tel. # Cell #  How Referred Laser Hair Removal Name of Birth Address City State Zip Home Tel. # Cell # Email How Referred Ethnic Background Previous Treatments Year Area(s) Hair and Skin Question - DO NOT use White, Jewish or Caucasian.

More information

Q-switched Nd:YAG Carbon Laser Facial Further treatment possible using your Tattoo Removal Laser

Q-switched Nd:YAG Carbon Laser Facial Further treatment possible using your Tattoo Removal Laser Q-switched Nd:YAG Carbon Laser Facial Further treatment possible using your Tattoo Removal Laser Carbon Laser Peel plus a mild form of Skin Rejuvenation Course Topics What is a Carbon Laser Facial? How

More information

Newport Cosmetic Center

Newport Cosmetic Center Shirin Afrasiabi, M.D, Inc. 2301 Newport Blvd, Costa Mesa, Ca 92627 (949) 548-5700 Appointment: Initial. We require a valid Credit Card at the time of booking to secure your appointment Cancellation and

More information

Eyelash Extension Consultation Form

Eyelash Extension Consultation Form Eyelash Extension Consultation Form Date Name Address City State Zip Cell # Is it ok to text this phone? Yes / No *we use text messaging as a way to send appointment confirmations Birthday: E-Mail Address

More information

Elite Beauty Essentials

Elite Beauty Essentials Elite Beauty Essentials P E R M A N E N T M A K E U P W I L L N O T B E PERFORMED IF YOU ARE PREGNANT, NURSING or TRYING!!! NO EXCEPTIONS! If you are late for your appointment you will be rescheduled.

More information

Intake Form Chemical Peels, Microdermabrasion, and Facials

Intake Form Chemical Peels, Microdermabrasion, and Facials Intake Form Chemical Peels, Microdermabrasion, and Facials Name: Today s Date: Last First MI Street address: City: State: Zip: Date of birth: Age: Sex: 0 Female 0 Male Home Phone: Cell Phone: Leave messages

More information

Areas of Concern. Patient s Name Last First Date

Areas of Concern. Patient s Name Last First Date Areas of Concern What are your main concerns for today s visit? Please check the problem areas that concern you. Include anything you wish to discuss, even if it is not the main reason for your visit.

More information

IPL CONTRAINDICATIONS

IPL CONTRAINDICATIONS IPL CONTRAINDICATIONS CONTRAINDICATIONS AND EXCLUSION CRITERIA FOR IPL APPLICATOR TREATMENTS CONTRAINDICATIONS - Please initial that you don t have any of these conditions. Superficial metal or other implants

More information

CLIENT QUESTIONNAIRE

CLIENT QUESTIONNAIRE CLIENT QUESTIONNAIRE YOUR INFORMATION Name Age DOB Address City State Zip Home Phone Cell Phone Email MEDICATIONS Medication When How Long Medication When How Long Antibiotics Androstendione Accutane Testosterone

More information

513 West Maple Ave West, Vienna, VA

513 West Maple Ave West, Vienna, VA `MEDICAL HISTORY FORM Last Name: First Name: Address: City: State: Zip Code: Telephone: Home: Work: Cell: Date of Birth: Sex: Female Male Family Doctor: Phone: Pharmacy: Phone: Emergency Contact: Phone:

More information

NEW PATIENT FORM. Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State) (Zip code) Home #: ( ) Work Number : ( )

NEW PATIENT FORM. Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State) (Zip code) Home #: ( ) Work Number : ( ) Office Use Only: Booker Mailchimp Referral Driver s License NEW PATIENT FORM Today s Date: Reason(s) for Today s Visit: Full Name: Date of Birth Age : (First) (Middle) (Last) Address: (Street) (City) (State)

More information

Arch Envy Eyebrow Consent and Release Agreement

Arch Envy Eyebrow Consent and Release Agreement Arch Envy Eyebrow Consent and Release Agreement This form is designed to give informa 椀爀 on needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery semi permanent make up

More information

SOUTH BAY LIPO LIGHT

SOUTH BAY LIPO LIGHT SOUTH BAY LIPO LIGHT FACIAL TREATMENT INTAKE FORM Your success is our #1 priority. PLEASE ANSWER ALL QUESTIONS Help us to help you achieve success by filling out this questionnaire as completely as possible.

More information

LUXE Beauty Ink Permanent Cosmetic Tattoo Artistry by Lynne SW Greenburg Rd., Suite 113 Tigard, OR

LUXE Beauty Ink Permanent Cosmetic Tattoo Artistry by Lynne SW Greenburg Rd., Suite 113 Tigard, OR LUXE Beauty Ink 11825 SW Greenburg Rd., Suite 113 Tigard, OR 97223 COSMETIC TATTOO PRE-TREATMENT INSTRUCTIONS If possible, do not take aspirin or other blood thinners 5-7 days before the procedure to prevent

More information

Personal Profile and Health History

Personal Profile and Health History --CAPITAL AESTHETICS Personal Profile and Health History Name: Home Phone: Address: Work Phone: City/State/Zip: Date of Birth: Age: Gender: M F Occupation: Email address: How did you hear about us? What

More information

East Hill Medical Group

East Hill Medical Group Name: of Birth: Address: City: State: Zip: Home Tel. #: Cell #: Employer: Occupation: Emergency Contact: Relationship: Phone: Email: How Referred: Parents Ethnic Background: Previous Treatments Year: Area(s):

More information

Pre & Post (BBL)Laser Hair Removal Treatment Instructions

Pre & Post (BBL)Laser Hair Removal Treatment Instructions Pre & Post (BBL)Laser Hair Removal Treatment Instructions Pre-Treatment Recommendations: Apply SPF 30 (or higher) sunblock at all times on areas to be treated that are exposed to any sun. Shave the area

More information

PREPARATION AND RISKS. Be sure to read through all the information I have provided and call with any questions at (608)

PREPARATION AND RISKS. Be sure to read through all the information I have provided and call with any questions at (608) PREPARATION AND RISKS Be sure to read through all the information I have provided and call with any questions at (608) 772-0190 The following is information I d like to share to help prepare you better

More information

Client Consultation. Date of Birth: Address: Home Phone: ( ) Business Phone: ( ) Referred by:

Client Consultation. Date of Birth: Address: Home Phone: ( ) Business Phone: ( ) Referred by: Client Consultation Date: Name: Date of Birth: Address: Home Phone: ( ) Business Phone: ( ) Cell Phone: ( ) E-mail address: Married: Single: Employer: Occupation: Does your job require that you work outdoors?

More information

CLIENTELE FORM. Name Date Address City State/Zip Referred by Phone Carrier

CLIENTELE FORM. Name  Date Address City State/Zip Referred by Phone Carrier Name Email Date Address City State/Zip Referred by Phone Carrier TO AOID COMPLICATIONS ANSWER THE FOLLOWING QUESTIONS, IF YES PLEASE EXPLAIN: Are you under the age of 18? Have you had any aspirin or blood

More information

Pre- & Post Hair Removal Instructions and Home-Care Regimen

Pre- & Post Hair Removal Instructions and Home-Care Regimen Pre- & Post Hair Removal Instructions and Home-Care Regimen Pre-Hair Removal Regimen: Avoid sun exposure or tanning beds to the area being treated. The laser may be less effective on burned or tanned skin.

More information

New Patient Registration

New Patient Registration New Patient Registration Today s Date: Social Security Number: Name: Last First MIddle How do you like to be addressed: Date of Birth: Address: Street City State Zip Email Address: Preferred Contact Number:

More information