Loading...

Studio Sohn Ombre Brow Consent Form

I hereby authorize Sarah Sohn of Studio Sohn to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises in the course of the procedure(s) I further request and authorize her to use her full judgement and do whatever he/ she deems advisable and necessary in the circumstances. 

I understand that permanent cosmetic enhancement is an advanced form of tattooing.



I accept responsibility for determining the color, shape and position of the enhancement as agreed during the course of my consultation. 


I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs. 


I am aware that a sensitivity reaction to anesthetics can occur and accept all responsibility if allergic response occurs. 


I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over time. Even though the color has faded, the pigment will stay in the skin indefinitely and may leave a light residue of color. 


I understand that dyes, inks and pigments are not approved by the Food and Drug Administration (FDA) and the health effects are not known. 


I accept that the highest standards of hygiene are met, and that sterile disposable needles 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 that this is why I may need to return for a touchup procedure that is included in the initial price. 


I understand that the touchup procedure, if required, will be performed 4-8 weeks after the initial procedure and that after the 8 week period I will be charged an additional fee for any procedures. 


 

PERMANENT BROW AFTERCARE 

  • Expect slight swelling and a little redness in the immediate area. 
  • Keep the area lightly moist using a Q-Tip with sterile Aquaphor 1or 2 times a day (morning 
  • and night) for 7-10 days. If slight crust appears on pigmented surface, do not force removal by picking or scratching!! (You will remove pigment along with crusting) Brows are not considered healed until all crusting has exfoliated. 
  • Avoid washing treated area for the first 24 hours. 
  • After the first day wash with mild soap and water and pat dry. 
  • Avoid eyebrow pencils and do not put powder on the brows (to lighten) 
  • Avoid tinting of brows for 3 weeks following the procedure. 
  • Avoid hot, steamy, long showers. A thin coat of Aquaphor over the pigment is a good idea  before showering. 
  • The procedure may have some peeling on or around the 3rd day. This is a normal process of  healing for some clients. Do not Pick... picking can cause scarring and loss of color. 
  • The application of permanent cosmetics can be a 2 step procedure. Do not judge your  procedure while in the healing stage. It may require a touch up. 
  • Don’t be alarmed if color comes off on to the Q-Tip when applying topical ointment. This is  normal. 
  • Avoid the gym or sweating for 3-5 days following the procedure. 
  • Avoid sun for 7-10 days following the procedure. 
  • Avoid chlorine pools, saunas and jacuzzis. 
  • Avoid makeup on pigmented area until healed. 
  • Avoid Retin A, Glycolic Acids, Aloe, and Vitamin E products. 
  • No Terry Towels on pigmented areas. 
  • No Gardening for the first 3-4 days to prevent possible infection. 
  • If you are planning a chemical peel, MRI, or other medical procedures inform them that you  have had an iron oxide cosmetic tattoo. 
  • You must wait 1 year after any tattoo to give blood. 
  • Lasers can cause pigment to turn black. Avoid the procedure site. 
  • If any signs of infection occur, abnormal swelling, redness or pain associated with the  procedure, call you physician (and please give us a call). 
  • After you have healed, use a good sunscreen daily to help prevent premature fading of all  procedures.


I am aware that the result of the procedure is determined by the following:

  • Medication 
  • Skin Characteristics - i.e. dry/oily/sun-damaged Natural skin undertones 
  • Alcohol intake and smoking 
  • General stress 
  • A compromised immune system
  • Poor diet 
  • Post procedure care treatment 

 


I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-2 days. In some cases bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited for up to two weeks following the procedure.  



I understand that immediately after the procedure the enhancement can be 40% to 60% darker than the desired result and can take between 7-10 days to lighten. I understand that the true color will be visible 1 month after each application, and that the color may vary according to skin type, age, medication and skin conditions. I appreciate that some skins accept color more readily than others and no guarantee of an exact effect or color can be given.  


I agree to inform my doctor of my permanent cosmetic enhancement if I require a MRI scan within a 3 month period of receiving the procedure.  


I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner. I understand that infection and possible scarring can occur if I do not adhere to the said instructions.  


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.

I am not under the influence of drugs or alcohol.  


For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s). I give my consent for before and after pictures to be used for marketing.  


I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL. 
I have read an understood the above information. 

INDIVIDUAL CONSENT 
I declare that I give my full consent to the tattooing being carried out by the aforementioned practitioner. I confirm that potential complications, e.g. infection and swelling, for the procedure undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed. 
I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e. 18 years old for tattoos) and that I am not currently under the influence of alcohol or drugs.’

Today's Date: January 7, 2025

 

COMPANY POLICY

Everyone's time is valuable and to ensure that I can provide for all my clients the best possible, I please ask everyone to arrive on time. If you are to be late please be aware that if you are more than 15 mins late you will have to reschedule because thiof service can not be rushed or cut short and deposit will be forfeited.

If you need to cancel or reschedule, please do so 72 hours before your appointment.

I reserve the right to charge 50% of the service if the appointment is cancelled or rescheduled within 24hrs.
I reserve the right for all deposits/exchanges to be non-refundable.

***First time clients must deposit $100 to secure appointment.

Today's Date: January 7, 2025

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Card On File

16-digit number *

Expiration Date *

Security Code *

Billing Zip Code *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation:

List all the medications you have been taking in the last 6 month
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?*
No
Yes
Have you received chemotherapy or radiation treatment in the last year?*
No
Yes

Name of Doctor:

Surgery:
Allergies: have you ever had an allergic reaction to any of the following:
Antibiotic ointments Medication
Drugs
Paints
Latex
Rubber
Metals
Foods
Crayons
Nuts
Hair dyes
Lidocaine
Glycerine Anesthetics

If Glycerine Anesthetics, which ones:

Other allergies (list):
Have you had a dental injection to numb your mouth?*
No
Yes
Are you presently pregnant or breast feeding?*
No
Yes
MRI scan scheduled in the next 3 months*
No
Yes
Laser or IPL scheduled in the next 3 months*
No
Yes
Do you give blood?*
No
Yes
Prior to dental procedures do you receive antibiotic therapy?*
No
Yes
Please fill out the following table with a tick to indicate if any of the following relate to yourself.
Abnormal Heart Condition
Palpitations
Mitral Valve Prolapsed
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus Erythematosus
Hepatitis
Shingles
Seizures
Impetigo
Cataracts
Blurred Vision
Dry Eyes
Do you suffer from eye Infections
Alopecia
Occular Herpes
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Recent Hair Loss
Cold Sores (herpes simplex)
Auto immune conditions
Gore-Tex Implants/Silicone Injections
Other Tattoos
Fat Injections
Bruise or Bleed Easily
Botox Enhancement
Use of Sun bed
Dermal Fillers i.e restylane
Do you have Healing Problems
Chemical or laser peel within 6 months
Do you scar in a raised manner?
Retin A within 6 months
Do your scars heal a darker color
AHA preparations within last 2 weeks
Keloid Scars
Sensitivity to Cosmetics
Acutance within 6 months
Do you tan regularly?
Steroids within 6 months
Asthma
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!