Client Intake and Consent for Microblading & SMP Form | Specializing in state of the art and skincare treatments in advanced follicle replication of the eyebrows and scalp

0 Client Intake and Consent for Microblading & SMP

Arch & Crown Aesthetics

886 Pompton Ave, Suite A1
Cedar Grove NJ, 07009

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 understand there are no refunds for this procedure as results vary and individual results are not guaranteed.

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:

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