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 Upper & Lower Eyeliner Upper OR Lower Eyeliner Eye Shadow Lip Liner Full Lips Micro Needling Unilateral Areola Bilateral Areolas Please circle either yes or no for each question listed below. 1 YES NO Are you pregnant or nursing? 27 YES NO Do you have prosthetic implants? 2 YES NO Have you had any alcohol in the last 24 hours? 28 YES NO Do you consume aspirin daily? 3 YES NO Have you ever had cold sores or fever blisters? 29 YES NO Are you under treatment for depression? 4 YES NO Do you have any allergies to latex? 30 YES NO Do you have any type of herpes? 5 YES NO Have you had a laser or chemical peel within the last 6 months? 31 YES NO Are you sensitive to petroleum based products or Vitamin E? 6 YES NO Do you routinely use Retin-A, glycolic, or other exfoliating products? 7 YES NO Do you menstruate? If yes: Next cycle date 32 YES NO 8 YES NO Have you ever had any permanent cosmetics or tattoos applied? 34 YES NO If you have permanent cosmetics or tattoos, did you have any problems with healing after they were applied? 33 YES NO Are you undergoing radiation or chemo-therapy treatment? Are you now, or have you ever been on the acne treatment Accutane? 9 YES NO Do you wear contact lenses? 35 YES NO Are you wearing a pacemaker? 10 YES NO Do you have Botox injections? 36 YES NO Do you take prescription drugs? Please list on the next page. 11 YES NO Do you have any problems healing? 37 YES NO Are you anemic? 12 YES NO Is your skin oily? 38 YES NO Do you have a history of skin sensitivities? 13 YES NO Do you use tobacco? If you use tobacco you may heal slower and this affects the timing on scheduling a touchup appointment, if applicable. 39 YES NO Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedures? 14 YES NO Do you have any heart conditions? 40 YES NO Do you have allergies to makeup? 15 YES NO Are you diabetic? If so, Type 1 or Type 2? 41 YES NO Do you have dry eyes? 16 YES NO Do you have any autoimmune disorders? 42 YES NO Do you intentionally tan Direct sun or tanning bed? 17 YES NO Are you sensitive or allergic to hand creams or body lotions? 43 YES NO Do you personally have any history of cancer? 18 YES NO Do you have your lips injected with filler materials? 44 YES NO Do you have a history of stroke or heart attack? 19 YES NO 20 YES NO 21 YES NO Are you allergic or sensitive to any metals, example: metals used for jewelry? Do you bruise easily for no obvious reason? Do you bleed excessively from minor cuts or been diagnosed as a Hemophiliac? 45 YES NO To your knowledge are you allergic or resistant to over the counter level numbing products such as ELA-Max (Lidocaine)? 46 YES NO Do you hypo-pigment? (Lack of pigment on the skin)? 47 YES NO Are you allergic to hair dyes? 22 YES NO Do you tend to develop keloid or hypertrophy scars? 48 YES NO Do you have glaucoma or any other eye disease? 23 YES NO Do you scar easily from minor skin injuries? 49 YES NO Do you have arthritis? 24 YES NO Do you have any seizure related conditions? 50 YES NO Do you have high or low blood pressure? 25 YES NO Do you have a tendency to faint or become dizzy? 51 YES NO Do you have sinus issues? 26 YES NO Do you develop dark spots on the skin from wounds or sun (Hyperpigmentation))? 52 YES NO Have you experienced Hepatitis or Jaundice during the past 12 months? If you answered Yes to any questions above, use the reverse side of this form to provide an explanation. Correlate your explanations to a specific question number. A yes answer does not indicate you are not an acceptable candidate for permanent cosmetics. It may simply be information that is valuable to me as your technician as each person s body is unique, or it may indicate that based on any health conditions that affect healing, it would be advisable or required for you to consult with your physician before proceeding. If this form has not addressed a medical condition you have, please list it on the next sheet. Client s Signature Date Technician s Name Michelle Brantley Tech s Signature:
Question # Medication Log Date Taken Medication Name Dosage Reason Taken Name Date.
The nature and method of the proposed cosmetic tattoo procedure(s) has been explained to me by Michelle Brantley, including the usual risks inherent in the procedure process, and the possibility of complications during and following the procedure(s). I understand there may be a certain amount of discomfort or pain associated with the procedure(s) and that other adverse side effects may include minor and temporary bleeding, bruising, swelling, and/or redness or other discolorations. Fading or loss of pigment may occur. Due to swelling, unevenness may occur in the design. Secondary infection in the area of the procedure may occur, however, adherence to the written after care instruction given by Michelle Brantley will help minimize the occurrence. (Initial) *I am not pregnant. (Initial) Cosmetic Tattoo Consent Form * I am not under the influence of alcohol and/or drugs. (Initial) * I acknowledge that complications as a result of a cosmetic tattoo procedure (s) may include infection, particularly in the event my post-procedural instructions are not followed. (Initial) * I do not have medical or skin conditions such as, but not limited to: acne, scarring (Keloids), eczema, psoriasis, freckles, moles, or sunburn in the area to be tattooed that may interfere with said tattoo. I do not have an infection or a visible rash anywhere on my body, I have advised my technician. (Initial) *I acknowledge it is not reasonably possible for the technician to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risk by waiving a patch test and understand that such a reaction is possible. If I want a patch test I understand it will take 24hours to determine my eligibility for said tattooing and I must inform the technician before signing this agreement.. (Initial only if waiving a test patch) * It has been explained to me, immediately after the procedure(s) is completed, the color will appear darker and bolder. It has also been explained to me that within a short period of time (usually 5-7 days) during the healing process, the color will lighten/soften and the design/procedure will heal softer than it looked the day it was performed (Please do not pick any scabs and be aware pigment can stain clothing and sheets). (Initial) * I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), 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 the technician cannot predict how my body will react as a result of this procedure. (Initial) * I acknowledge that the procedure(s) will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. Tattoo removal is a surgical procedure which may cause scarring and/or disfigurement. (Initial) * I understand that future laser treatments, plastic surgery, implants, injections, and other skin altering procedures ay alter and degrade my cosmetic tattoo procedure(s). I further understand that such changes are NOT the responsibility of the technician, and such changes in my appearance may NOT be correctable through further cosmetic tattoo procedures. (Initial) * I understand that tattoos may cause MRI (Magnetic Response Imaging) artifacts and that there may be a warming and/or tingling sensation in the tattooed area during the MRI due to the iron oxide properties of some pigments. It is understood that I should advise my physician that I do have permanent cosmetics (a tattoo) in the event a MRI procedure is prescribed. (Initial) * I authorize the technician to obtain pre-procedural and post-procedural pictures, and give her permission to use such pictures for publication and/or teaching purposes, as she chooses. (Initial)
* I acknowledge the receipt of written instructions advising me of the proper care of my procedure(s),and ointment by the technician. I understand the absolute necessity for following these instructions. (Initial) * I understand that cosmetic tattooing is an art form and NOT an exact science, and I acknowledge that NO guarantees have been made to me as to the result of this procedure. Some skin types will not accept or heal pigment in a consistent manner your skin and how well you take care of your cosmetic tattoo(s) will determine your result. I realize that my body and my skin are unique and that the technician cannot in any way predict how your skin may react to the procedure or how it may or may not accept color. A touch up is recommended and encouraged. I also realize that the technician cannot predict how many visits it will take to complete my procedure. (Initial) * I accept full responsibility for determining the color, shape and position of the pigments that will be applied. I understand the actual healed color of the pigment applied will be modified slightly due to my own unique skin undertones. (Initial) * This contract is to remain in effect from the date signed by the client and its contents are to still apply whenever work is being performed on myself by the technician. It is my responsibility to inform the technician if any changes have occurred in my medical history. (Initial) * I have read and understand the contents of each paragraph above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of the aforementioned procedure(s). (Initial) I, (print name), acknowledge by signing this consent form, have been given the full opportunity to ask the technician any and all questions about cosmetic tattooing procedure(s), it s process, and the risks involved from the technician. The decision to have cosmetic tattooing procedure(s) performed is my own and I understand and accept all risks involved, therefore releasing Michelle Brantley of any and all legal liability. In consideration of her tattooing me, I hereby release and forever discharge her and her employees both personally and under the business name of SeaChelle s Permanent Makeup LLC from all claims, demands, actions and causes of actions arising out of said treatment procedures which I, my heirs, executors, administrators, or assigns may have stemming from my decision to have either a Permanent Makeup procedure and/or an Areola/Nipple procedure. I agree that this waiver also pertains to and is designed to protect any and all establishments where Michelle Brantley does business. The technician is a trained, experienced, and skilled artist who makes no claims to be anything more. Permanent makeup/cosmetic tattooing is not a medical procedure, but is an art form: the art of tattooing. Any and all fees are to be paid prior to or on the day of the procedure and are nonrefundable. Client's Signature: Date:. Technician's Signature: Date:. Michelle Brantley Signature of parent or legal guardian if client is under 18 years of age: Date:.
Procedure Log Amount Paid: Procedure Date: Client's Name: Procedure(s): Anesthetics Used: Method Used: Nouveau Contour Coil Manual Needle: Lot Number: Expiration Date: Needle: Lot Number: Expiration Date: By signing below, client agrees that all the information above is true and correct to the best of his/her knowledge and that he/she is happy with the services rendered by Michelle Brantley. In addition, the client will contact Michelle Brantley if he/she needs a touch-up or adjustments to the work rendered today. Your happiness with the end result is important and may take more than one treatment to accomplish this goal. Client's Signature: Technician s Signature: Location of the Procedure: Michelle Brantley Date: Date:
Colors: AREOLA DIAGRAM
Touch-Up Appointment Agreement I, agree that all paperwork filled out on is accurate and applies to today s appointment. Please write below anything that has changed since your last appointment. Signed: Date: Colors used during today s appointment:
TOUCH-UP AREOLA DIAGRAM Colors: Date
SeaChelle s Permanent Makeup LLC Michelle Brantley Licensed Tattooist: #41441556206Esthetician License: #FB9713368 In regards to the Areola/Nipple Tattooing, I, am responsible for the total payment. In addition, I understand that the technician, Michelle Brantley will not bill my insurance company for any procedures. Also, I was made aware that Michelle Brantley only does self-pay cosmetic procedures. However, if I bill my insurance company, any money (s) paid toward the procedure will be forwarded to me. I also understand that I will not be reimbursed by Michelle Brantley the difference between the insurance allowable amount and the total amount paid to Michelle Brantley. Signature: Client Date: Signature: Witness Date:
SeaChelle s Permanent Make-up LLC By Michelle Brantley (941)744-7890 Licensed Tattooist: #41441556206 Esthetician License: #FB9713368 Insurance Paperwork Instructions 1. Please ask your referring physician to give you a paper on his/her letterhead stating: a. when you were diagnosed and/or the date if you had a reoccurrence b. The physician saying you are ready for areolas breast tattoos c. And ask for the physician s NPI number and write it on the insurance claim form (section 17b) 2. Fill out the 1500 Health Insurance Claim Form (all sections:1-17b) a. DO NOT sign section 13. This is only signed when the client wants the reimbursement to come back to me. By signing section 12 only, any money the insurance company decides to reimburse will go to you. b. Make a copy of your driver s license and a copy of the front and back of your insurance card. Send the copy and all the paperwork to your insurance company. c. Call me if your insurance company denies your claim. I will send you an appeal letter that you can send to your insurance company. Contact Number: (941)744-7890 Website: http://www.permanentmakeup.vpweb.com Social Media: http://www.facebook.com/seachellespermanentmakeup
SeaChelle s Permanent MakeupLLC Michelle Brantley Licensed Tattooist: #41441556206 Aesthetician License: #FB9713368 To Who It May Concern, This letter is being sent to you in regards to a claim made by me, Michelle Brantley, on behalf of my client,. Currently, I am working out of network, however, I do have a National Provider Number (NPI Number: 1811385370 ). Attached to this document is the 1500 Health Insurance Claim Form along with the client's copy of her insurance card, and, if possible, a copy of the client's physician s authorization letter. These are being sent to you with hopes of helping my client receive reimbursement payment for tattooing of her areola (s). Thank you for your time on this matter and I look forward to working with your company in the future. Sincerely yours, Michelle Brantley NPI Number: 1811385370 EIN Number: 80-0375923 Michelle Brantley Phone (941)744-7890 Website:http://permanentmakeup.vpweb.com/ Social Media:https://www.facebook.com/SeaChellesPermanentMakeUp
SeaChelle s Permanent Makeup, LLC Michelle Brantley (941)744-7890 CLIENT POST PROCEDURE INSTRUCTIONS AREOLA AND NIPPLE MICRO-PIGMENTATION AFTER CARE 1. Cavilon 3M was applied immediately after your procedure. It is used to help prevent debris from entering the tattoo (be advised it only lasts for 2-3 days and does not guarantee prevention of an infection). Also, it does not create a barrier tough enough to lock in seepage. 2. Please leave the bandage that was applied at your appointment on until it is time to shower. 3. WHEN SHOWERING THE FIRST TIME, make sure your hands are thoroughly clean then gently wash and cleanse the breast area with a mild cleanser, such as Hibiclens, Phisoderm, Phisohex, Dial, Cetaphyl, or baby shampoo. DO NOT use anything astringent or harsh. Do not let hot water spray directly onto your tattooed breasts. Continue to rinse until the surface appears clean and free of blood, ointment, and soap. You will not need to use soap every time you shower. 3a. WHEN SHOWERING ON OTHER DAYS/NIGHTS, add A&D ointment with a sterile Q-tip on the tattooed area before entering the shower. This will repel the water and any soap that may accidentally touch the tattooed area. Do NOT let hot water spray directly onto your tattooed breasts. Also, please do not touch the area often, less is best. 4. DRY the tattoo by blotting very gently with either a clean paper product or a clean towel. Air dry for 15 to 30 minutes or until the tattoo is dry (tattoo will feel tight when it is thoroughly dry). 5. Once completely dry and you are ready to clothe yourself, add enough A&D ointment with a sterile Q-tip to the tattooed area to cover the entire area and then apply a new bandage. This will help protect your tattoo (s) and anything that may stain: clothing, sheets, etc. 6. The new bandage will need to be replaced every night for one week. Repeat steps 3a, 4, & 5 6. Throughout the day, check to see if there is MOISTURE UNDER THE DRESSING, (pigment appears to be pooling under the bandage). Gently lift the bandage from the bottom then lightly pat the tattooed area only if there is liquid/fluids then place the bandage back down. Please make sure to not touch the area, remember less is best.
What should you expect afterward the procedure? 1. SLIGHT SWELLING and redness following the procedure and the skin may feel tight and/or sensitive, these symptoms will ease within 1 7 days depending on how sensitive your skin is.. 2. For 7 days (or until peeling is complete) DO NOT expose your tattoos to dust or dirt. DO NOT exercise or cause sweat in the area of your tattoo. NO mud wrestling or wash the dog you get the idea. If you want to use the new tattoos as an excuse to get out of housework, I ve got your back! The truth is, you may clean your house. Just don t sweat! 3. PEELING can begin around the 4 th day. DO NOT PICK, PEEL, RUB OR SCRATCH the epithelial crust, ALLOW IT TO FLAKE OFF ON ITS OWN, otherwise your color may heal unevenly and you risk infection. It is important that the healing process takes its natural course! As the pigmented area of the skin heals and dries, it forms a scab. This can last 14 21 days and the dead cells (the scab) will come off as healing takes place. Scarring can occur if the scabs are removed or knocked off prematurely. 4. Some itching is normal. You may consider taking Benadryl if that helps 5. At first, your tattoos will appear dark, this is normal. You will start to notice slight fading of the pigment and softening of the color as it heals. Your tattoo may have a waxy or shiny appearance when it first peels, this is normal. 6. DO NOT expose your tattoos to the sun, tanning beds, lake water, ponds, oceans, hot tubs, pools, saunas and puddles for the first two weeks of the healing phase. There is a great risk of infection as well as lack of pigment retention as a result. 7. Gently pat dry following showers or baths even 2 to 3 months after tattooing procedure, allowing optimal time for healing. Colors appear brighter and more sharply defined immediately following the procedure. As the healing progresses, color will soften. Final results cannot be determined until healing is complete in about 6 weeks. It is important to remember that permanent makeup is an art and not an exact science. Two important factors will contribute to the success of your final outcome and are reliant on: 1. How well you follow the post procedure instructions. 2. Your own body s ability to retain the pigment (which varies from person to person). In most all cases, a touch up visit may be necessary. It must be completed within a reasonable amount of time after the initial procedure is complete, but cannot be done before 6 weeks. After your appointment, you were given a touch up appointment. Locking in the color the second time allows the tattoo to last longer and the touch up provides an opportunity for any possible adjustments to color, shape, or size. Please contact Michelle for any concerns or questions Contact Number: (941)744-7890 Website: www.permanentmakeup.vpweb.com
PRACTICE SHEET
Date NAME: DATE Correspondence Log CORRESPONDENCE LOG