Scar Revision intake form Name(Required) First Last Address(Required) Street Address City/State Postal Code Phone(Required)Email(Required) Birthdate(Required) MM slash DD slash YYYY Emergency Contact Name(Required) First Last Emergency Contact Phone(Required)Please select all that apply to you Are you pregnant Do you have healing problems? Are you lactating Do you form a keloid? Have you tanned for the last 30 days? Are you using Retin A in the area you want to treat within 6 months? How old are you scars/stretch marks? Do you have sensitivity to cosmetics Are you diabetic? Are you taking steroids? Allergies Anesthetic Latex Rubber Glycerine Medication Metals Hair dyes Drugs Antibiotic ointments Lidocaine Please put a check next to anything that applies to you Abnormal Heart Condition Circulatory Problems Stroke Mitral Valve Prolapsed Epilepsy Prosthetic Hip or Joint Rheumatic Fever Thyroid Disturbances Hepatitis Artificial Heart Valves Kidney Disease Palpitations Haemophilia Stomach Ulcers Pacemaker High Blood Pressure Cancer Anaemia Heart Murmur Prolonged Bleeding Low Blood Pressure Fainting Spells or Dizziness Liver Disease Glaucoma Tumours, Growths or Cysts Tuberculosis Auto immune disease Systemic Lupus Erythematosus Shingles Waiver / Release FormPlease read each bullet carefully before signing. Please check on every number to indicate that you’ve read and understand it. Untitled(Required) 1. I absolutely understand and accept that the camouflage procedure is a process, often requiring multiple sessions to achieve desirable results, and that 100% success cannot be guaranteed. Untitled(Required) 2. I have received, reviewed, and understood the pre & post-procedural instructions as given to me and agree to follow them. Untitled(Required) 3. I accept responsibility for my aftercare. I understand that I need to follow it in order to protect the color of my tattoo and to prevent infection. Untitled(Required) 4. I understand that the color selection and color results in all procedures are not an exact science and that the right color for my skin tone might not be achieved in just one session. Untitled(Required) 5. I understand that since the pigment used for this treatment is a skin-tone pigment, this color cannot be erased even by laser treatment. Untitled(Required) 6. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics (tattoo). When asked if you have a tattoo, you say yes. Untitled(Required) 7. I understand that the healing process may take up to six months and that it varies depending on my skin’s healing abilities. Untitled(Required) 8. I understand that the color of my camouflage will be darker than my skin tone while it's healing. Untitled(Required) 9. I understand that a camouflage tattoo is a procedure that may or may not fade and that it might require a touch-up after a couple of years. Untitled(Required) 10. It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness, and swelling, darkening of the skin that may take a couple of months. Untitled(Required) 11. I understand that many lasers & IPLs (Intense Pulse Lights), including those used for hair removal, anti-aging, Photo Facials, removal of lines, may or will turn permanent makeup dark or even black. I agree to inform my esthetician or anyone operating such devices that I have permanent makeup. Untitled(Required) 12. I understand that since this is a treatment that requires incision of needles in my skin, this might cause keloids depending on how my skin will react. Untitled(Required) 13. I am aware that if an infection occurs after I have received Permanent Cosmetics, I am to see my primary physician or an emergency room physician immediately and at my own expense. Untitled(Required) 14. I give my consent to Nue Conceal to confer with my physicians, if needed, for medical information required for the safety of my procedures. Untitled(Required) 15. I agree to accompany my practitioner to the emergency room and take a blood test in the event they were to be accidentally stuck with my needle for their safety and disclose all test results to my practitioner. Untitled(Required) 16. If I had permanent cosmetics performed previously by another practitioner, my new PMU artist will not be held responsible for future allergic reactions or contraindications. Untitled(Required) 17. I understand that since this is a tattoo treatment done in scar tissue, every skin may react differently and may lead to more skin damage which is beyond my artist’s control. ACCEPTANCE: I have read and understand these risks listed above and they have been explained to me one by one. I DID NOT SIMPLY SIGN THIS DOCUMENT WITHOUT READING IT. I certify that the information in the above questionnaire is accurate and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request . I hereby waive and release, indemnify, hold harmless and forever discharge, the company, my artist, the manufacturer of the product (Nue Conceal), all it’s employees and owners from any responsibility and/or liability regarding any services and treatments.Printed Name(Required) First Last Signature(Required)Today's Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
