A Perfect Touch Permanent Makeup Imagine…permanent, no-run, waterproof color, hassle-free! Always fresh, Always Beautiful! (970) 389-0904

CLIENT REGISTRATION FOR PERMANENT MAKEUP (Please complete all information)

I. Client Information: Name: ______Date: ______Address: ______Date of Birth: ______City: ______State: ______Zip: ______Home Phone: ( ) ______Cell Phone: ( ) ______*If OK to call at work, Work Phone: ( ) ______Email Address: ______Drivers License #: ______State: ______Emergency Contact: ______Phone #: ( ) ______Family Physician: ______Phone #: ( ) ______How did you hear about me? ______Why do you want Permanent Makeup? ______

II. Photo Release: Client authorizes the technician performing this procedure and / or the owner of the establishment where the procedure is being performed unrestrictive use of before and after photographs to include but not limited to portfolio, marketing, advertising and explaining of procedures. Initial: ______

III. Medical History: - Have you ever had Permanent Makeup done before? Yes or No If yes, what procedure(s): ______By Whom? ______When: ______Name of Color: ______Method of Implantation? ______Were you pleased with the result? Yes or If NOT , please explain why? ______What would you like to achieve with your Permanent Makeup? ______

Please list any prescription(s), herbs, or vitamins you are taking: ______- Do you take or use any of the following medications: _____ Accutane _____ Insulin _____ Blood Thinners _____ Anabuse ______Steroids (including Cortisones) _____Aspirin _____High Blood Pressure Meds _____ Anti-Coagulants - Do you need to take Antibiotics or Anti-Viral Medicine prior to or after seeing your dentist? _____ Yes ______No - Have Implants or Injectable Fillers: ____No If yes, where on the body and when was the procedure done? ______Are you completely healed? ______- Have you recently undergone or plan to undergo any elective or necessary surgery or laser procedures? ______

*** Client is aware that laser can fade Permanent Makeup or turn implanted color black and that it must be disclosed to the laser technician prior to receiving any laser treatments. ______Initial ***

- Do you have any known ? Please check all that apply and list additional allergies in the space provided: _____ Latex _____ Glycerin _____ Iron Oxides _____ Paba _____ Epinephrine _____ “-caine” products such as Tetracaine, Lidocaine, etc _____ Petroleum-based products ______Bacitracin, Other: ______

- Have you ever had any difficulties/complications with dental procedures: If yes, please describe: ______

- Do you use any Retinoic Acids (Rx form of Vitamin A including Retin-A, Diferin, Adapalene, Renova, Tazorac, etc.) or Glycolic Acids regularly on the or neck? _____ No or, if Yes what kind, strength and frequency of use? ______*** Client must stop using 2 weeks prior to all procedures !!! ______Initial***

- Do you swim or tan (natural sun or tanning bed)? ______*** Do not tan 3 days before or after appointments. _____ Initial ***

- For Clients: Do you use “all day” or “long-lasting” or stains? _____ No ______Yes *** If Yes, you must stop use because they dry out the . If you are having a lip procedure, then your lips will be tough, making implanting color more challenging if not impossible. Stop wearing this type of and start exfoliating the lips daily by lightly brushing lips after brushing teeth or by gently rubbing the lips with a clean, damp washcloth. Begin wearing a moisturizing lip-gloss, balm or moisturizing lipstick as often as possible including before going to bed. _____ Initial ***

- Have you ever in your life experienced a cold sore, fever blister, sun blister or Herpes Simplex? _____ No _____ Yes *** If Yes, client acknowledges that she must get a prescription for Valtrex, Acyclovir, Famvir, Zovirax or other Anti-Viral medication and use for at least 5 days before, during, and 5 days after the procedure if having a lip procedure or periorbital birthmark. ***Client is aware that Fever Blisters can occur with any lip or periorbital procedure regardless of preventative measures and that such occurrence will drastically reduce the quantity of pigment that is implanted. Additional applications may be needed to complete the procedure to the client’s satis- faction and additional fees may be incurred. _____ Initial

Dentures: _____ Yes _____ No Which teeth? ______

For Eyeliner Clients: It is imperative that you not consume anything with caffeine or other stimulants (unless they are medically necessary) on the day of your procedure(s) as it causes the eyes to be tense and twitchy. The effects of stimulants make the procedure somewhat uncomfortable for the client and difficult for the technician to achieve precision and efficiency in the application. - I am aware that if I have difficulty relaxing my eyes due to the effects of stimulants (that are not medically necessary), I may have to be rescheduled & charged an additional $50 fee. _____Initial***

- Do you wear: Contact Lenses ______Eyeglasses: ______***Contacts must be removed prior to any eyeliner procedure and left out for at least 3 days post- procedure. Please bring glasses with you to your appointments.

(Consent and Release Form continues on the next page)

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Please circle any of the following conditions below that you have or have had in the past.

Blepharitis Mental Illness Dermatitis Lupus Thyroid Issues Hemophilia Pregnant Diabetes Smoker Mastectomy Cancer Alopecia Conjunctivitis Epilepsy HIV Hepatitis Eye Disorders Tissue Asthma Oily Skin Dry Skin Combo Skin Normal Skin Keloids Seizures Surgeries Hyperpigmentation Hypopigmentation Radiation Fainting Sinusitis Cold Sores Fever Blisters Retin A Laser Bruising Hematomas Trichotillomania Renova Allergies Shingles Injectable Fillers Collagen Accutane Glaucoma Bleed Easily Healing Problems Restylane Differin Cataracts Facial Trauma Hormone Therapy Lip Implants Adapalene Eczema Steroids Cosmetic Botox Psoriasis Dry Eye Metal High/Low Blood Autoimmune Syndrome Allergies Pressure Disorders

Please explain: ______

Please explain any other medical conditions: ______

*** Client agrees to make aware to the technician any and all personal and relevant medical history, to the best of the Client’s ability. _____ Initial ***

IV. Statement of Consent and Recitals: Please initial all lines! _____ Before and After instructions have been explained orally and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have any questions, I will call the technician who performed my procedure. _____ I understand that a certain amount of discomfort is associated with this procedure and that minor or temporary swelling, redness, or tenderness may be experienced. The technician will make every effort to make you as comfortable as possible before, during, and after the procedure. _____ I understand that fever blisters, cold sores, or Herpes Simplex breakouts may occur on the lips following a lip procedure in individuals who are prone to this problem. Fading or loss of pigment may occur at site of outbreak as a result. I understand that even with a doctor’s prescription anti-viral, and outbreak is possible and will not hold the technician or owner responsible for any outbreaks or loss of pigment as a result of said outbreak. I also understand that if loss of pigment occurs due to an outbreak that additional Touch-Ups may be required and will incur additional application fees. _____ I understand that it is my responsibility to obtain a prescription from a doctor or dentist for fever blister medication to help avoid an outbreak.

3 _____ I understand that Permanent Makeup is a multi-session procedure requiring more than one visit to perfect. All procedures take at least 30 days to completely heal. I understand that touch-up applications must be scheduled within 30-45 days from date of initial application. _____ I understand that I must be off Accutane for at least 12 months prior to any Permanent Makeup Procedure. _____ I understand that successful lip saturation cannot be guaranteed due to hidden scar tissue. _____ If I am a tobacco user, I understand that the healing process may be negatively affected and I may have difficulty with color retention. _____ I understand that I must wait one year following any tattoo/Permanent Makeup procedure before donating blood (Red Cross Instructions). _____ I understand that I must inform all skin care professionals, medical personnel or their cosmetic tattoo technician of any Permanent Makeup treatments. _____ I understand that I must inform all medical personnel about my Permanent Makeup prior to an MRI as the iron oxide pigments may show up on imaging and that while rare, some tingling may be felt. _____ I accept the responsibility for explaining to the performing technician my desired color, shape, position and location of pigment for any cosmetic tattoo/permanent makeup/reconstructive tattoo procedure. _____ I understand that since Permanent Makeup is an art not a science, the performing technician cannot guarantee the outcome of the procedure. The reason is due to the fact that there are so many variables related to the client, i.e. following After-Care instructions, sun exposure, medications, anti- aging creams, client’s medical condition, lifestyle, etc. _____ I understand that implanted pigment can turn color or fade over time due to circumstances beyond the control of the performing technician. The original color may be altered by such things as sun exposure, tanning beds, skin care products (especially anti-aging products like Retinols, Alpha & Beta Hydroxy Acids, etc), pools, salinity levels of each person’s eyes/skin, general health and other factors. I understand that I will need to maintain the color with future applications. _____ The nature of the proposed Permanent Makeup procedure has been explained. _____ All risks and possible complications have been explained. _____ I acknowledge and accept that the proposed procedure(s) all involve risks inherent in the procedure and the possibility of complications exists both during and following the procedure. , misplaced pigment, migrating pigment, poor color retention, hyper-pigmentation or fever blisters are a few of the possible complications. _____ I understand that if I decide to change the color or shape after the initial application or in the future, that I may need an additional session(s) to achieve the desired result and depth of color. _____ I understand that even with a patch test, an allergic reaction may occur months or years later. _____ I agree to a patch test and the 7 day waiting period or, _____ I choose to waive the patch test and 7 day waiting period and am aware of the possible risks and complications. _____ I certify that I read and understand all of the above. _____ I have answered all questions truthfully and to the best of my knowledge. _____ I accept the permanence of the procedure(s) as wells as the possible complications and consequences of the said procedure(s) _____ I certify that I have read and initialed the above paragraphs and have had explained to my full understanding this consent for treatment and the nature and risks of the procedure(s). _____ I accept full responsibility for the decision to have this cosmetic procedure(s). _____ I, ______, am over the age of 18, am not under the influence of any drugs or alcohol and desire to receive the indicated Permanent Makeup procedure(s). The general nature of cosmetic tattooing as well as the specific procedure(s) to be performed has been explained to my satisfaction.

4 I, ______, hereby consent to having Permanent Makeup applied by Karyn Blanco with A Perfect Touch, LLC.

V. Arbitration Agreement In the event of any controversy/disagreement between CLIENT and the TECHNICIAN, involving a claim or “tort” “and all other claims”, the same shall be submitted to arbitration. Within 15 days of controversy/disagreement, the CLIENT and the TECHNICIAN shall give notice to the other of demanding arbitration of such controversy, and the parties to the controversy shall appoint an arbitrator and give notice of such appointment to the other. Within a reasonable amount of time after such notices have been given, the two arbitrators, so elected, shall select a neutral arbitrator and give notice of the selection thereof to the parties. The arbitrator shall hold a hearing within a reasonable amount of time from the date of selection of the neutral arbitrator. All notices of other papers required to be served shall be served by the United States mail. _____ Initial

VI. Acknowledgements I understand that there will be NO refunds after treatment of this elective procedure(s). I understand my payment includes a total of 3 visits (Initial Consultation, Initial Application Session, and Follow-Up Session, if needed). The Follow-Up Session must be scheduled for completion no later than 60 days from date of Initial Application. It is the responsibility of the client to contact the technician within 30-45 days of Initial Application to schedule the Follow-Up Session. Up to 2 weeks may be needed to schedule an appointment so please schedule as far in advance as possible!!! ____ Initial*

NOTE: If client has only 1 application, then decides 3-6 months later she/he wants her/his 2 nd application, the client will be charged for the Touch-Up according to the section below. Why? Permanent Makeup needs to be layered-on or fading may occur – a total of at least 2 applications are required, in many cases, to achieve the final outcome. The touch-up application ideally should be no more than 4-6 weeks and no longer than 2 months from the initial application. _____ Initial***

Future Touch-Up/Color Change applications will be charged $150 for Brow/Liner/Lash Enhancements, $200 for Thick Upper & Lower Eyeliner/Thick Brow/, $250 for Full/Blended Lips per session for up to 3 years from initial application. After 3 years pricing will be determined on an individual basis. The number of Touch-Up appointments required to achieve the desired result may vary. _____ Initial***

VI. Payment(s)

I, ______, have paid Karyn Blanco / A Perfect Touch, LLC, in the amount of $ ______, for the procedure(s): ______, to be performed initially on: ______, and completed by: ______.

Paid by: ___ Cash ___ Check ___ Visa ___ M/C ___ Discover ___ American Express

Signature of Client: ______Date: ______Signature of Technician: ______Date: ______

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Client Name: ______

Skin Tone Analysis Worksheet

Please answer ALL questions. There is no right or wrong answer, just answer to the best of your ability.

Fitzpatrick Skin Type: Circle the answer that “best” describes you. Without sunscreen or sunblock, I … I. Always burns, never tans II. Always burns, occasionally tans III. Often burns, tans gradually IV. Burns minimally, tans well V. Burns rarely, tans profusely (usually dark brown skin, black hair, and very dark eyes) VI. Never burns, deeply pigmented (black skin, black hair, very dark eyes.

Would you say your skin is (circle one): Meditterranean (olive), Transparent (fair), Translucent (clear blue undertone, like Snow White), Ruddy (rosy red or pink), Native American (mistaken for olive but really a warm, yellow undertone), Golden Girl (peaches and cream or Barbie-like), Asian (sallow tone), African (light may be golden toned, darker may have bluish undertones), or Aboriginal (warm yellow or red undertones)

Ethnicity (used only to determine possible undertones in skin): ______

Circle which color best describes your “natural” hair color as a child (circle one): Ash blonde, golden blonde, strawberry blonde, golden red, auburn red, light-golden brown, medium-golden brown, ash brown, medium brown, dark brown, warm/golden gray, ash gray, salt ‘n’ pepper, silver, charcoal gray

Circle which color best describes your “natural” hair color as an adult (circle one): Ash blonde, golden blonde, strawberry blonde, golden red, auburn red, light-golden brown, medium-golden brown, ash brown, medium brown, dark brown, warm/golden gray, ash gray, salt ‘n’ pepper, silver, charcoal gray

Choose what best describes your eye color (circle all that apply): Blue, blue/gray, blue with gold flecks, blue with brown flecks, blue/green, green/gray, green with gold flecks, green with brown flecks, amber, brown, dark brown

If you wear jewelry do you prefer to wear (circle one): Gold, Silver, Pewter

Circle the colors that you think or have heard look best on you (circle all that apply): Silver, black, white, pale pink, hot pink, burgundy, gray, lilac purple, baby blue, emerald green, pale yellow, gold, brown, ivory, peach, pumpkin, rust, beige, olive green, mustard yellow, purple, navy blue, royal blue, red.

Please draw, in the space below, the shape, thickness, design, and effect you desire with your application and a smudge of the desired color: Color Smudge:

*** I, ______, have answered the above questions to the best of my ability and have expressed my desired result with my technician. _____ Initial

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