CLIENT REGISTRATION
Name
______________________________________________________Date___________________
Address____________________________________________________________________________
City
_______________________________ Zip code
_______________________________________
Home
Phone (
)_____________________________________________________________________
Work
Phone (
)__________________________________Email: _____________________________
Drivers
License # (AZ requires proof you are
over 18) _______________________________________
Emergency
Contact Information: Name ___________________________ Phone#__________________
How
did you hear about me?
____________________________________________________________
Why
do you want permanent makeup? ____________________________________________________
______________________________________________________________________________________
Client
authorizes Jane Adler unrestrictive use of before and after photographs to
include but not limited to portfolio and teaching. Initial___________________________
* I must have a picture of all clients!
Physician’s
name_______________________________________________________________________
Do
you wear: Contact
Lenses____________Eyeglasses___________ Dentures___________
Have
you recently undergone or plan to undergo any elective or necessary facial
surgery or laser procedures?
____________________________________________________________
Have
you ever had Permanent Makeup done before?
Yes or No
If
yes: What procedure(s)?
_________________________________________________________________________
By
Whom?
_____________________________________________________________________________________
How
long ago?
__________________________________________________________________________________
What
would you like to achieve with your permanent makeup?
_______________________________________________________________________________________________
Were you pleased with the
results of the work? If NOT please
explain why?
Do
you have any known allergies?
________________________________________________________
Are you allergic to: ___ Latex ___Glycerin___ Paba ___ Epinephrine __ Caine Products______
Do
you have any lip implants, gortex, collagen or other? This may cause poor lip
tattoo retention._______
Do
you use Retin A, Renova or Glycolic Acids regularly? If yes, please stop using two weeks
prior to all procedures!!! _____________
Initial
Must
be off Accutane 6 month’s prior all too all procedures! One year for lips
_______________Initial
Planning
on laser treatments?? Can fade makeup or
turn lip color black. __________________Initial
If
you have or have had any of the following conditions please initial and explain
in details!
|
Blepharitis
|
Autoimmune
|
Mental
Illness
|
Dry
eye syndrome
|
High
Blood Pressure
|
|
Dermatitis
|
Lupus
|
Thyroid
|
Hemophilia
|
Chemotherapy
|
|
Pregnant
|
Diabetes
|
Metal
allergies
|
Smoke
|
Mastectomy
|
|
Heart
problems
|
Cancer
|
Alopecia
|
Conjunctivitis
|
Epilepsy
|
|
HIV
|
Eye
disorders
|
Blood
thinners
|
Cosmetic
allergy
|
Hormone
Therapy
|
|
Hepatitis
|
Scar
tissue
|
Asthma
|
Chicken pox
|
Oily
skin
|
|
Seizures
|
Surgeries
|
Hyperpigmentaiton
|
Hypopigmentation
|
Dry
Skin
|
|
Faint
|
Keloids
|
Sinusitis
|
Radiation
|
Combination
Skin
|
|
Blood
Disorders
|
Cold
Sores
|
Fever
Blisters
|
Allergies to Cosmetics
|
Healing
Problems
|
|
Retin
A
|
Laser
|
Trichotillomania
|
Bruising
|
Chapped
Lips
|
|
Renova
|
Allergies
|
Plastic
Surgery
|
Hematomas
|
Collagen
|
|
Accutane
|
Shingles
|
Facial
Trauma
|
Glaucoma
|
Bleed
Easily
|
Please
List All
CurrentMedications__________________________________________________________
______________________________________________________________________________________
* Explain any other major medical conditions!
_______________________________________________
_____________________________________________________________________________________
Do
you take any of the following medications?____ Accutane _____Insulin _____Blood
thinners _____Annabuse ____Steroids ____ Aspirin_____ High Blood Pressure
_____Anti-coagulants ____
Do
you need to take Antibiotics prior to seeing your dentist? Yes or
No
Are
you using Latisse or similar
products? Yes or No
Do
you have any known skin conditions or skin cancer? Yes
or No
Jane
Adler does not recommend any client get
a dental block prior to lip tattooing in AZ! Initial ______
If
you have ever had a fever blister or cold sore you agree to take a prescription
medication from your doctor or dentist.
You must take Valtrax or Zovirax orally before and during any lip tattoo
procedures
_______________________
Initial * Fever Blisters can occur with any lip procedure! 90% have virus!
Do
you swim or tan (sun or tanning bed)? Do
not tan before or after appointment!______________ Initial
_________
Before & After instruction 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 Jane Adler. Please
use the after care ointment supplied by Jane Adler, unless causes irritation.
_________
I understand that a certain amount of discomfort is associated with this
procedure and that minor or temporary swelling, redness, or fever blisters may
occur on the lips following lip tattoo procedures in individual who are prone
to this problem. Fading or loss of pigment can happen.
_________ I understand the permanent makeup is a multi
session procedure requiring more than one visit to perfect in most cases. All
procedures take at least 30 days to heal and evaluate. Some will need only one
session. Permanent Makeup is a process
not a procedure.
_________
I understand that sun, tanning beds, pools skin care products and medications
can affect my permanent makeup!
_________
I understand that Retin A, Renova must not be used around the treated areas
long term. I must stop using 2 weeks prior to my sessions. These products can
fade permanent makeup.
_________
I understand I must be off Accutane 6 months prior to procedure(s). One-year prior for lips.
_________
I understand that successful lip saturation cannot be guaranteed due to hidden
scar tissue.
_________
I understand it is my responsibility to obtain a prescription for fever
blister medication to help avoid an outbreak from a doctor or dentist. Studies
show 90% of people carry the virus. Oral tablets.
_________
Client has been informed to wait one year following any tattoo before donating
blood.
_________
Client has been informed to tell all skin care professional, medical personnel
or their cosmetic tattoo prior to any treatments. Please have them put a protective barrier
over all procedures to protect.
__________
I understand to inform medical personnel about my permanent makeup prior to an
MRI.
________
I accept the responsibility for explaining to Jane Adler my desire for specific
color, shape and position for eyebrows, eyeliner, lips, and camouflage or
Areola restoration.
________
I understand that implanted pigment can turn color or fade over time due to
circumstances beyond the control of Jane Adler and alter the original pigment
color. I understand I will need to
maintain the color with future applications.
Sun, skin care products, pools and other factors play a role in pigment
fading on the face. An allergic reaction can occur, most common with topicals
and after care.
_________ I acknowledge that the proposed procedure (s)
all involve risks inherent in the procedure and the possibility of
complications during and following the procedure. Infection, missed placed
pigment, poor color retention, hyperpigmentation or fever blisters or allergic
reaction.
_________
I hear by consent to having permanent makeup applied by Jane Adler with Facial
Art by Jane. I have answered all questions truthfully and to the best of my
knowledge. I certify that I have read and understood all of the above.
_________
I understand I can have an allergy scratch test by request.
*
Jane Adler will use a fresh pre-sterilized needle(s) and pigment for all
procedures. Jane Adler follows all OSHA
standards on all clients. Fresh gloves
are worn for all procedures!
I have paid Jane Adler the amount of:___________________________________________________
For the procedure(s)
_________________________________________________________________
I
understand there will be no refunds upon treatment for this elective
procedure(s). I understand my payment
includes _______________ visits within
45 days of initial application. It is
the responsibility of the client to contact Jane Adler with in 45 days after
initial session if a touch up is required.
Additional visits for Touch ups will require further payment of: * Be
sure to book Touch up if needed after initial application with in 45 days!!!!!!
Additional touches up fees are: This
will range on an individual basis from 1 to 10 years. If you do not book a follow up appointment in the
time allowed you will forfeit your complimentary follow-up and be
charged the below fees. Eyes $150.00, Brows $150.00, Lips $200.00, Other
________.
Date________________________
Client
Signature:
____________________________________________________________________________
Jane
Adler___________________________________________________________________________________
All specials for 2012 are cash or check only!!
Touch
ups are cash or check too.
Credit
cards are for on regular pricing only and do not apply to any specials!
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