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) : 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 _____ Brows ____ Eyes _____Lips _____Other /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) _____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 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 procedures in individuals prone to this problem. Fading or loss of pigment may occur. Secondary 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 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 , 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. • /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 Eyebrows: You may bring your own pencil/powder to your appointment. You may arrive with brows already drawn in so I have an idea how you normally wear them. Eyeliner: No contacts during or for 2 days following procedure. Bring glasses if needed. NO LASH EXTENSIONS. Lips: For dry/chapped lips use a damp washcloth to exfoliate lips 1-2 days prior and keep moisturized. Take anti-viral as needed.

GOOD TO KNOW • Permanent makeup is a multi-session process that may require 1-2 follow-up/detail visits, which occur 6-8 weeks after the initial procedure. Maintenance visits thereafter vary between 1-5 years. Permanent makeup fades over time due to the nature of our skin, body chemistry, skincare products, medications and environment. • Initial swelling, redness, healing, peeling & fading are all normal. Color will be dark & intense at first. Healing process is usually complete within 7-14 days. Plan social events accordingly. • You will be asked to not over-saturate procedural area with water or sweat for 1 week. Quick showers with head to back. No saunas, oceans, pools, hot tubs, etc. for 2 weeks. • Permanent makeup will not be performed if you are pregnant or nursing. • If you are required to be on antibiotics prior to any type of procedure including dental, you must obtain a doctor’s clearance letter and/or appropriate medication prior to the permanent makeup procedure. • You will not be able to wear topical makeup in procedural area for 5 days.

*Permanent makeup is not an exact science; starting off with a conservative approach allows room to add more. Less is more.

Permanent makeup is not a replacement for your topical makeup - it is a natural enhancement to your features. Many clients will still wear makeup over their permanent makeup and use the permanent makeup as a guideline to follow. (Once healed, permanent makeup is muted and sits under your skin - your topical makeup is on top and will always be more vivid.)

From Jill, your artist: My goal is to give you natural looking permanent makeup for a “Timeless” look. Think about your permanent makeup as an enhancement and not a replacement of your everyday makeup. Many clients find permanent makeup convenient for going to the store, school drop off, exercising etc. Heavy, thickly applied permanent makeup won’t look like your makeup - it will look like a tattoo. For this reason I prefer a natural look.

During your healing process if you have unanswered questions or need more information please contact us via phone at 408.395.7792 or via email at [email protected]

TO AVOID ADDITIONAL FEES, PLEASE REMEMBER OUR 48-HR RESCHEDULE POLICY Timeless Skin Spa POST-CARE INSTRUCTIONS/INFORMATION

*If you've read through this and still have questions during healing, email or call us. [email protected] or 408.395.7792 After-Care What you shouldn't do EXPECTATIONS *One of the following will apply: • If instructed, wait 24-48 hrs before starting aftercare. Then, for 1 week, gently wipe with a damp • Do not over saturate area with water or sweat Slight swelling and/or redness. or q-tip 2x's a day. After cleaning, use a for 1 week. Take quick showers w/head to back; no First 24-48 Hours Brow appears darker and thicker than when fully healed. clean q-tip to apply a very small amount of fragrance- saunas, oceans, pools, hot tubs, etc for 2 weeks. free until healed or no longer dry. •For 1 week gently wipe with damp cotton pad or q- • Do not pick or pull at excess skin/flakes during tips 2x's a day. If given an ointment (Aquaphor) use a healing & peeling stage. Healing & Peeling ~ Brows will become dry, itchy, flaky & will peel. As clean q-tip to apply a very light layer for 2 days then Weeks 1-2 peeling finishes color appears lighter & may appear ashy or gray as • Do not wear makeup in procedural area for 5 switch to a fragrance-free lotion until your skin is pigment settles in skin. days. healed & no longer dry. • For 1 week gently wipe with damp cotton pad or q- Actual color & shape reveals. You may wear pencil or powder in tips 2x's a day. After cleaning use a clean q-tip to • Do not be in direct sunlight for 2 weeks; may Weeks 3-6 areas where pigment didn't take until your 6 week follow-up/detail apply a very small amount of fragrance-free lotion until apply sunscreen in brows after 1 week. visit. Don't be alarmed by how much lighter your brows became. healed or no longer dry. Eyeliner After-Care What you shouldn't do EXPECTATIONSSpa • Do not over saturate area with water or sweat Slight swelling & redness. Morning of Day 2 is normally when swelling for 1 week. Take quick showers w/head to back; no First 24-48 Hours will peak. Liner appears darker & thicker than when fully healed. saunas, oceans, pools, hot tubs, etc for 2 weeks. • For one week gently wipe with a damp cotton pad • Do not pick or pull at excess skin/flakes during Healing & Peeling - Liner will appear to come off in flakes or peel. or q-tips 2x's a day (am/pm). Do not use ointment or Weeks 1-2 healing & peeling stage. Don't be alarmed how much thinner & lighter in color the liner is. lotion unless advised. • Do not wear makeup in procedural area forSkin 5 Actual color & shape reveals. You may wear makeup in areas where days. Weeks 3-6 pigment didn't take until your 6 week follow-up/detail visit. • Do not be in direct sunlight for 2 weeks. Lip After-Care What you shouldn't do EXPECTATIONS • For one week gently wipe with a damp cotton pad • Do not over saturate area with water or sweat or q-tips 2x's a day. After cleaning & as needed for at Swelling & tenderess. Lips appear darker & fuller than when fully for 1 wees. Take quick showers w/head to back; no Days 1-3 least 2 weeks, apply given ointment to prevent normal healed. saunas, oceans, pools, hot tubs, etc for 2 weeks. dryness that occurs during healing. • Do not pick or pull at excess skin/flakes during Healing & Peeling - Lips are dry & chapped as they heal. Color Weeks 1-2 healing & peeling stage. continues to bloom back & forth in lip tissue. H • Do drink through a straw & eat carfully to avoid to • Do not be in direct sunlight for 2 weeks; may Healing is primarily complete. Although you may continue to see avoid contact with acidic and spicy food for several apply sunscreen after 1 week. additional color changes based on your body temperature. Lips feel days Weeks 3-6 • Avoid toothpaste on lips; do not use bleaching dry for a month or two. Use a good & sunscreen. Don't be Timelessdental products for 4 weeks. alarmed at how much lighter lip color becomes. FOR ALL PROCEDURES: • The initial color of the tattoo is dark & on top of your skin - it will heal, peel & fade • Do not oversaturate procedural area with water or sweat for 1 week. Quick showers with head to back. no matter what. Keep in mind, topical makeup is placed on top of your skin always No saunas, oceans, pools, hot tubs, etc., for 2 weeks. appearing more vivid than permanent makeup which is placed & heals under the skin. • Don't use exfoliants on areas as they cause fading. After procedural area is healed, • Initial swelling, redness, healing, peeling & fading are all normal. Color will be dark & intense at first. SPF use will help prevent fading. • As needed for swelling control: wash hands, dampen cotton pads with water & place in a sealed bag in • Please only use what your instructed to- DO NOT use poly/neosporin, bacitracin etc. refrigerator. Once cooled, place on procedure area 1-3 x's daily for 2 days. Discard after one-time use. as these may pose allergic reactions or healing issues.