Permanent Makeup Registration Form Client InformationName(Required) First Last Drivers License Number Date of Birth MM slash DD slash YYYY Address Street Address City/State Postal Code Phone(Required)Email(Required) Who may we thank for referring you? Emergency ContactEmergency Contact Name First Emergency Contact PhonePHOTO RECORDA Photographic record will be taken of the work performed before and after each procedure and photos will be maintained as follows: Untitled(Required) As a private record only For classroom purposes as a model For display in office lobby As a case study in Professional Journal or publication For advertising purposes Medical HistoryAre you currently under the care of a physician?(Required) Yes No Physicians Name Physicians Address Please list any medications you are currently taking:Do you wear: Contact Lenses Eyeglasses Dentures Have you recently (in the last 6 months undergone or plan to undergo any elective or necessary facial surgery?(Required) Yes No *If Yes, when? Have you ever had any Permanent Cosmetics/Camouflaging procedures done before?(Required) Yes No *If yes, what procedure? By Whom? How Long Ago? Please check all Medical Conditions that currently apply to you Pregnant Cancer Glaucoma Eye Disease Scar heavily or Keloid when injured Hyperpigmentation (scars heal dark) Please check all Medical Conditions that currently apply to you Hemophilia Diabetes HIV Positive Skin Disorder Mitral Valve Prolapse Lupus Chemo/Radiation Therapy Please check all Medical Conditions that currently apply to you Fever Blisters/Cold Sores on Lips Dry Eye Syndrome Hay Fever Epilepsy Anemia Emphysema Asthma Alopecia Universalis Alopecia Areata Seasonal Allergies Please check if you are currently taking any of the following medications Accutane Antabuse Steroids Insulin Aspirin Blood Pressure Medication Blood Thinner Anti – coagulant Please check if you have any of the following allergies Latex Lidocaine Tetracaine Epinephrine Please list any other allergies you have (Food/Medicine/etc)Please check all that apply: I have a tattoo My tattoo behaves irregularly I have had tattoo removal I have had Gor-Tex implant (lip implants) I have had fat transfer injections I have had collagen injections I use a sunlamp or tanning bed regularly I get Botox injections I participate in outdoor activities I use Retin A, Retinol or Glycolic Acid regularly I am currently menstruating I am prone to cold sores/fever blisters Medical Infections: Please check any conditions that CURRENTLY apply to you: Mumps Meningitis Pneumonia Kidney disease Measles Scarlet Fever Mononucleosis Hepatitis Typhoid Fever Whooping Cough Venereal Disease Herpes Simplex II (genital) Chickenpox TB or Lung Disease Rheumatic Fever CONSENT TO PERMANENT COSMETICS PROCEDURE ARTIST LICENSE #1201580Name First Last Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of permanent cosmetics and that all my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows:Untitled(Required) If I have any condition that might affect the healing of this permanent cosmetics procedure, I will inform my artist. I am not pregnant or nursing. I am not under the influence of alcohol or drugs. Untitled(Required) I do not have medical or skin conditions such as but not limited to acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be tattooed that may interfere with said tattoo. If I have any type of infection or rash anywhere on my body, I will advise by artist. Untitled(Required) I acknowledge it is not reasonably possible for the representative and employees of this shop to determine whether I might have an allergic reaction to the pigments or processes used in my permanent cosmetics, and I agree to accept the risk that such a reaction is possible. Untitled(Required) I acknowledge that infection is always possible as a result of the obtaining of permanent cosmetics, particularly if I do not take proper care of my permanent cosmetics. I have received aftercare instructions and I agree to follow them during the healing process. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense. Untitled(Required) I realize that variations in color and design may exist between any permanent cosmetics as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the color will not appear as bright as they do on light skin. Untitled(Required) I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics Untitled(Required) I acknowledge that permanent cosmetics is a permanent change to my appearance and that no representations have been made to me as the ability to later change or remove my permanent cosmetics. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my wellbeing as a direct or indirect result of my decision to get permanent cosmetics. Untitled(Required) I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the permanent cosmetics shop reasonably necessary to perform the permanent cosmetics procedure. Untitled(Required) The nature and method of the proposed procedures have been explained by the technician as any risks or complications during and following its performance. Untitled(Required) I acknowledge that the requested procedure(s) was applied following Universal precautions as outlined by the CDC and my risk of infection begins the moment, I leave the facility. Untitled(Required) I understand that a certain amount of pain is associated with this procedure and that a minor or temporary redness; swelling or fever blisters may occur on the lips following lip procedures in individuals who are prone to this problem and or fading or loss of pigment. Untitled(Required) The technician has explained, and I understand that Permanent Cosmetics is a process, often requiring multiple applications of color to achieve desirable results. Untitled(Required) I understand that if I am prone to cold sores/fever blisters I will not receive a lip permanent cosmetics treatment unless I have taken the proper medication recommended by my doctor pharmacist. Untitled(Required) I understand that I can not receive permanent cosmetics procedure if I have had Botox in the last 2 weeks or filler injections in the 6 weeks. Are you a member of the military? Yes No If yes, which branch? SignatureToday's Date MM slash DD slash YYYY Client Consent For PhotographsName consents to, and authorizes Vitality Face & Body to use photographs of my procedure for:Untitled Internal documentation of my procedure Untitled For use in informational, educational, marketing or sales purposes. In addition to standard documentation of procedure. I understand that these photographs may appear on websites, in printed materials, in presentations or exhibits, or in other forms of media, as determined by Vitality Face & Body. SignatureCAPTCHANameThis field is for validation purposes and should be left unchanged.
