Client Intake Form for Lip BlushingSign Form Below! Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Emergency Contact * Please read these statements carefully! - Permanent cosmetics are a form of tattooing. - Re touch procedures may be required. - A healing period of 4 to 6 weeks is required before any touch-up procedure can be performed. - On rare occasions the pigment may migrate under the skin. - Application of permanent cosmetics can be uncomfortable. - The pigments will fade. - Immediately after the procedure, the pigment can be 30 to 50% darker than the desired result. - There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare. - A negative allergy test result will not guarantee that you will not have an allergic reaction. - Infections can occur if aftercare is not followed. - Allergic reactions to anaesthetics can occur. - There may be swelling and redness following the procedure. - You may experience minor bleeding. - If you have a MRI scan within 3 months your permanent cosmetics procedure we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.* * I have read and understand the above statement Medical Information Please list all the medication taken within the last 6 months that may be of PMU complications. Have you taken any of the following in the last 48 hours? * * Aspirin Ibuprofen Alcohol Caffeine Have you ever had an allergic reaction to any of the following:* * Anaesthetics Adrenaline Latex Rubber Vaseline Metals Drugs Paints Lanolin Foods Medication Glycerine Lidocaine Another allergy not listed above None of the above If 'yes' or 'another allergy' please provide additional information below Have you received chemotherapy or radiation treatment in the last year? * Yes No Medical Questions Please check any of the following that apply to you Abnormal Heart Condition Cold Sores (herpes simplex) Mitral Valve Prolapse Heart Murmur Pacemaker Artificial Heart Valves Anaemia Haemophilia Prolonged Bleeding High Blood Pressure High Blood Pressur Low Blood Pressure Circulatory Problems Diabetes Epilepsy Fainting Spells or Dizziness Thyroid Disturbances Liver Disease Kidney Disease Glaucoma Tumors, Growths, or Cysts Cancer Stroke HIV Prosthetic Hip or Joint Palpatations Alopecia Recent Hair Loss Chapped Lips Trichollomania Fat Transfer Injections Botox Injections Hypertrophic Scars Keloid Scars Scar Easily Healing Problems Bruise or Bleed Easily Sensitivity or Cosmetics Use of Sun Bed Acutance within 6 months Cortisone within 6 months Chemical or laser peel within 6 months Retin A whithin 6 months AHA preperations within last 2 weeks General Consent & Procedure Permit * I hereby authorize Creative Beauty's technician to perform Lip Blushing upon myself. If any unforeseen condition arises in the course of this procedure(s), calling in their judgement in addition to, or different from those now contemplated, I further request and authorise the technician to do whatever they deems advisable and necessary in the circumstances. I accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I confirm I have completed a patch test for this procedure, within 6 months of the treatment date. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-3 years. I have been informed that the highest standards of hygiene are met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results and that 100% success cannot be guaranteed. I understand this is why I need to return for a retouch procedure. I understand that a retouch procedure will be performed 1-3 months after the initial procedure and after a 3-month period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties. The result of the procedure is determined by the following: - Medication - Skin Characteristics - (dry, oily, sun-damaged and thickness) - Natural skin undertones - (blending with chosen pigment) - Personal pH balance of skin, which changes from visit to visit - Alcohol intake and smoking - Post procedure care treatment. Upon completion of the procedure there may be swelling and redness of the skin, which will subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately following the procedure, however, using cosmetics, excessive perspiration wetting and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. You can however, be assured the procedure, even after only one treatment, looks acceptable and you should feel comfortable appearing in public without additional makeup on the affected area. I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary in colour according to skin tones, skin type, age and skin conditions. I understand that some skins except pigment more readily than others and no guarantee to an exact effect or colour can be given. I am aware that the lip procedures may stimulate any dormant virus such as herpes (cold sores). I am informed that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment. To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old or older. I am not under the influence of drugs or alcohol, pregnant or breastfeeding. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by Creative Beauty’s Technician. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the microblading procedure(s) If you do not want pictures posted online please let your technician know.* I have read and understood the above information Topical Anaesthetic Form * Allergic Reaction– Allergic reaction can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptom associated with allergy. Numbness - We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is totally numb while others say they experience some discomfort. Procedure – For all procedures a cream or gel topical anaesthetic is used. These products are perfectly safe, and can be purchased over the counter from any chemist. The anaesthetic is placed over the treatment area for between twenty to thirty minutes then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between one and four days. You should always follow your post procedure instructions.* I have read and understood the above information By signing below, I agree to the following: I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this/these procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I accept full responsibility for the decision to have this cosmetic tattoo work done and understand that there is a no refund policy. I acknowledge that I have reviewed and approved the material given to me. * * ***I AM AWARE THAT THIS IS A NON REFUNDABLE SERVICE*** Sign Below. Full Name Date * Thank you!
