Client Intake and Consent for Microblading & SMP Form 0 Client Intake and Consent for Microblading & SMP Arch & Crown Aesthetics 110 Fairview Ave. Suite 3Verona NJ, 07044 Arch & Crown Aesthetics 110 Fairview Ave. Verona, NJ 07044 Info@archandcrownaesthetics.com Name : Date of Birth : Email : Ethnic Background (Please include all nationalities): Address: Apt. #: Home Phone: City: State: Zip Code: Cell Phone: Occupation: If we call you at home, do you want confidentiality? YesNo May we call you at work? YesNo If yes, my work number is : Emergency Contact Information: Name: Phone: Relationship: Who may we thank for referring you? Procedure(s) desired: BrowsSMPLips List all medications you are presently taking Name of Drug , mg or mcg , Amount/Day , Why it was prescribed to you? (One data per line) List all medications you took in the last six months that you are no longer taking Name of Drug , mg or mcg , Amount/Day , Why it was prescribed to you? (One data per line) GENERAL MEDICAL DO YOU HAVE (CHECK ALL THAT APPLY)Fever Blisters/Cold Sores (Ever, even one time)Glaucoma or other eye disease/disorderGrave’s DiseaseHeart DiseaseShingles History/Recent Shingles ShotMitral Valve ProlapseValve ImplantsPacemakerStentsDiabetes requiring insulinProblems with healingKeloidsSeizuresDermatological DisorderHemophilia or Clotting DisorderAutoimmune DisorderPre-existing nerve damageTattoosTrichotillomania (pulling of hair, brows, lashes)Alopecia Totalis or AreataAllergiesN/A If Checked Dermatological Disorder if So What : Active or in Flare-ups? : if Checked Tattoos, Colors you are sun sensitive to: ARE YOU? (CHECK ALL THAT APPLY)PregnantPlanning cosmetic surgeryCurrently under the care of a physicianN/A If Planing cosmetic surgery, what & when? if Currently under the care of a physician , Describe DO YOU USE (CHECK ALL THAT APPLY)Accutane (currently or within the past year)Antibiotics prior to dental proceduresSteroidsRetin-A, Glycolic Acid, Vitamin C or other ExfoliantsTanning BedsEyebrow TintingEyelash TintingLatisseBotoxChemical PeelsChemotherapy or Prophylactic dose of ChemotherapyBlood ThinnersN/A If Checked Botox, When If Checked Chemical Peels, When HAVE YOU HAD (CHECK ALL THAT APPLY)Fever Blisters/Cold Sores (Ever, even one time)Eye Infections (Are you prone to them)Vision Correction Procedure (Lasik, RK) within the past 3 monthsHeart AttackJoint Replacement, Organ TransplantEye TraumaSeizuresFainting SpellsHepatitisHepatitis TestFat Transfer InjectionsGore-Tex ImplantsAesthetic or Cosmetic ProceduresLaser TreatmentsN/A If Checked Heart Attack, When? If Checked Hepatitis, What type? If Checked Hepatitis Test, When? If Checked Fat Transfer Injections, where? If Checked Gore-Tex Implants, where? If Checked Aesthetic or Cosmetic Procedures, where? If Checked Laser Treatments, What type & why? INFORMED CONSENT TO PROCEDURE (PLEASE READ ALL QUESTIONS THOROUGHLY BEFORE SIGNING) 1. Are you pregnant or nursing? YesNo 2. I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed. YesNo 3. I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them. YesNo 4. Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color. YesNo 5. I understand that the color selection and color results in all procedures are not an exact science. YesNo 6. I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox, or Restalyne, and I assume this responsibility. YesNo 7. I understand that this procedure will fade and this fading can alter the original pigment color and that this determines that it is a time for a touch-up visit. YesNo 8. I realize this is an elective cosmetic procedure and is not medically necessary. YesNo 9. It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment. YesNo 10. I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up. YesNo 11. I give my consent to Arch & Crown to confer with my physicians for medical information required for the safety of my procedures. YesNo 12. I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner. YesNo 13. I am aware that if an infection occurs after I have received Permanent Cosmetics to see with my primary physician or an emergency room immediately. YesNo ACCEPTANCE: I have read and understand these risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and my questions have been answered. Signature of Client:
