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Permanent Cosmetics Skin General Para

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Permanent Cosmetics Skin General Para Timeless Skin Spa - Client History Date:__________Name:______________________________________________________Are you over 18?____ Address:_______________________________________________________________________________________ Tel: Home: ______________________Cell: _______________________ Work: _____________________________ Email ______________________________________Referred by: ________________________________________ Emergency Contact:___________________________________Tel:________________________________________ 1) List any medical, health, and skin condition(s): ____________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 2) List any medications, include topical, internal, prescription and non-prescriptions you are on: _____________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3) Allergies: Check all, which apply. _____Latex _____Tetracaine _____Sinus problems _____Metals _____Benzocaine Other Allergies:______________________ _____Lidocaine _____Epinephrine __________________________________________________ Do you or have you had any of the following? Check which apply, explain below or on another sheet if more space needed. Permanent Cosmetics _____ Brows ____ Eyes _____Lips _____Other Eyebrows/Eyes _____Use Latisse /other lash/brow growth product _____Alopecia _____Blurred Vision _____Contacts _____Dry Eyes _____Eye Makeup Sensitivity _____Eye Surgery _____Glaucoma _____Injectables (Botox, Restylane etc.) _____Trichotillomania (pull out brow hair or eyelashes) Lips _____Herpes (Cold sores, fever blisters) _____Injectables/Implants, (Botox, Juvederm, Collagen, etc.) Skin _____Bruise or bleed easily _____Shingles _____Skin sensitivities _____Suntan _____Cancer, tumors, growths _____Chemical Peels/Laser (in last 6 mo.) _____Treatment for Acne _____Use of Retin A, Glycolic, AHA’s _____Hyper pigment (skin turns dark) _____Healing Problems _____Scars (raised, white, discolored) _____Hypo pigment (skin turns lighter) General _____Arthritis _____Respiratory issues _____Use Vitamins A, E or Fish Oil _____Heart Conditions _____Hepatitis, HIV _____Take antibiotics prior dental procedures _____High/low blood pressure _____Hemophilia _____Take blood thinners, aspirin, Coumadin _____Past cosmetic surgery _____Future cosmetic surgery plans _____ Pregnant/Breast Feeding Explanations for above: _____________________________________________________________________________ Para-Medical Related Tattoo Areas Breast Cancer Related: List surgeon and date(s) of last surgeries: Mastectomy Surgeon ______________________________________________ Date_______________________________ Breast Recon. Surgeon______________________________________________ Date_______________________________ Nipple Recon. Surgeon______________________________________________ Date_______________________________ Other Areas________________________ Surgeon__________________________ Date_______________________________ This medical history has been reviewed with a technician and my questions have been satisfactorily answered. I have received and will follow pre and post-care instructions. The above answers are true and answered to the best of my knowledge. Client Signature:______________________________________________________ Date:________________________ NAME:__________________________________________________________ Pg 2 The nature and method of the proposed permanent makeup /cosmetic tattoo procedure has been explained to me by my technician and/or by her associate(s) including the usual risks inherent in the procedure process, and the possibility of complications during or following its performance. There may be a certain amount of discomfort or pain associated with the procedure and other adverse side effects may include minor and temporary bleeding, bruising, redness, corneal abrasion, pigment migration or other discoloration and swelling. Fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Fading or loss of pigment may occur. Secondary infection in the area of the procedure may occur, however, if properly cared for, is rare. There may be chances of an allergic reaction to the pigment and/or topical anesthetic, although rare, as well as a chance of scarring. Permanent cosmetics are tattoos and I could have an allergic reaction to pigments/dyes at any time, immediately or in years to come, whether I have a patch test or not. Therefore, I have waived the opportunity to have a patch test. I’ve informed my permanent cosmetics technician and/or her associates of existing health problems and medications. Hyper-pigmentation (darkening of skin), hypo-pigmentation (absence of color in the skin) or scarring is a possibility as result of my body’s reaction to tissue disruption during the procedure. My body is unique and my permanent cosmetics technician and/or her associate(s) cannot predict how my skin may react from this procedure. This procedure will result in a permanent change to my appearance and no representations have been made to me as to the ability to later change or remove the results. Future laser treatments or other skin altering procedures, such as plastic surgery, implants and injections may alter and degrade my permanent cosmetics. Such changes are not the responsibility of my permanent makeup technician and may not be correctable through further permanent cosmetics procedures. Cosmetic tattooing is not an exact science and there are no guarantees as to the results of the procedure; I may need multiple visits to achieve the desired results. My permanent cosmetics technician and/or her associate(s) may obtain pre-procedural and post-procedural photographs, and I give permission to use such photographs for publication and/or for teaching purposes, as they choose. Herpes Simplex I Virus (fever blisters or cold sores) may manifest with any lip procedure due to trauma to the lip tissue. The anticipation of a Herpes Simplex I Virus breakout may be pre-treated with anti-viral medication, some of which are available by prescription only from my physician. The fee for permanent cosmetics has been explained and agreed upon. Immediately after the procedure(s) is completed, the color will appear darker than when it has healed. Within a short period of time (usually 5-7 days), during the healing process, the color will lighten. Permanent cosmetics also fade over time in relation to UV sunrays; swimming pools and skin care products. If I were ever to have an MRI, I should advise my X-Ray Technician of my permanent cosmetics. If I donate blood, it is a Red Cross policy that I must wait one year after tattooing. (Check your state rules.) I’ve read, acknowledge and understand the contents of the paragraphs above. I have received no unrealistic guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). The undersigned acknowledges that Jill Hoyer has explained the nature of the treatment procedure including the risk and dangers inherent therein. I hereby consent to Jill Hoyer performing permanent tattooing procedures on me and in consideration of her doing so, I hereby release and forever discharge Jill Hoyer and her employees both personally and under the business name of Timeless Skin Spa, from all claims, demands, actions, and causes of actions arising out of said treatment which I, my heirs, executors, administrators, or assignees may have stemming from my decision to have a permanent makeup / cosmetic procedure performed by Jill Hoyer. Any legal action will be by way of binding arbitration through a mediation firm. I agree that this waiver also pertains to and is designed to protect any and all establishments where Jill Hoyer does business. I acknowledge by signing this consent form, have been given the full opportunity to ask any and all questions about permanent cosmetic procedure(s) and process(s) from my permanent cosmetics technician and/or her associate(s). SIGNATURE:_______________________________________________ DATE:_______________________________ Timeless Skin Spa 413 B Monterey Ave. Los Gatos, CA 95030 408.395.7792 [email protected] Timeless Skin Spa Pre-Care Instructions & Information PRE-PROCEDURAL DIRECTIONS NOTE: Never discontinue the use of any medication that has been prescribed by your physician without his/her consent. Please inform your artist in the event continued use is required. 2 weeks prior, refrain from: • Botox (may have 2 weeks after final follow–up /detail visit) • Latisse/hair growth products (may be resumed 2 weeks after final follow-up/detail visit) • Lash/brow tinting or perming (may be resumed 2 weeks after final follow-up/detail visit) • Lash extensions (may be resumed 2 weeks after final follow-up/detail visit) 2-5 days prior, refrain from: • Blood-thinning products (i.e. alcohol, aspirin-containing products including ibuprofen, baby aspirin, as well as Vitamins A, E and Fish Oil). Tylenol is fine. • Waxing/Tweezing (may resume 5 days post) • Electrolysis (may resume 5 days post) • For lip procedures, if you have a history of cold sores/fever blisters/ herpes you must obtain an antiviral prescription medication to help prevent a potential outbreak. DAY OF APPOINTMENT
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