Pre procedure Questionairre for Permanent Cosmetics

Name__________________

Address________________
________________________________________________________

Email______________________

Phone:  (H)________          (W)_____________        (C)________

 

·   Are you pregnant or nursing?

·   Are you scheduled for or considering vision correction surgery?

·   Have you recently had facial surgery, Botox, fillers such as Restalyne, Sculptra, etc. or any type of lip augmentation?

·   Are you on Blood thinners such as Coumadin, etc., steroids such as Prednisone, Chemotherapy or Prophylactic Chemotherapy?

·   Do you have a fever blister, at this time or have you ever had even one fever blister in your lifetime?

·   Are you on Accutane for treatment of Acne?

·   Do you have a heart valve replacement, stents, Mitral Valve Prolapse, Rheumatic Fever or any heart condition?

·   Are you pre-medicated prior to dental work?

·   Do you have a joint replacement?

·   Are you an insulin dependent diabetic?
 
·   Do you have any dermatologic disorders such as Shingles, Rosacia, Eczema, and Psoriasis and are they active?

·   Do you have any medical condition that has you presently in the care of a doctor or believe I may need medical clearance for?
 
·   Have you had permanent make up, previously?


If you have had a previous procedure, please describe the color that is remaining so I will know whether you need a touch-up or correction.

·   Do you plan on going on a vacation (in the sun) in the next 2 weeks?
 
·   How wide do you wear your eyeliner?

·   How much hair do you have in your brow?

·   Do you want full lip color or a liner with shading?

 
All permanent cosmetic procedures are multi-session processes. You are required to come back for at least one touch-up visit before
it can be determined that your work is complete. Touch-up visits are scheduled approximately six week to three-month intervals.

Be prepared for the color intensity of your procedure to be significantly brighter or darker as well as larger and sharper,
than what is expected for the final outcome.  It will take time for this transition, (1to 2 weeks for brows and eyeliner. Six weeks
for lips) based on how quickly the outer layer of your skin exfoliates.

While these injected tones may initially simulate the exact color and tone desired, it will not always remain a perfect match.
Injected tones are constant, while your own skin tones will vary depending on exposure to cold, heat, sun and circulatory changes.
For example, if you tan your skin and had a scar camouflaged your surrounding skin will be darker in appearance than the treated area.

Since delicate skin or sensitive areas may swell slightly or redden, some clients feel it best not to make any social plans for a
day or two following a procedure. Allow a minimum of 1 month healing from time of procedures for significant events. This reduces stress for all.

Wear your normal make-up and bring your lip or brow pencils to the office on the day of the procedure.

Any eyelash or eyebrow tinting or eyelash curling should be done no sooner than 48 hours before or two weeks after the procedure.

Do not wear contact lenses during or immediately following the eyeliner procedure. Remember to bring your glasses!
You may resume wearing your contact lenses as soon as your eyes return to their pre-tattooed condition.               

Please sign below and bring completed form with your first visit. Feel free to call An Ultimate You at 845-598-8748 with any questions.           

 

Signature_________________________________           Date_________________

Technicians Signature___________________             Date_________________
                                      
 
Consultation and Consent Form for
Nouveau Lash Extension
 
Name: __________________________________

Address: _______________________________

________________________________________

 
Phone:     H:________________      W:_________________      C:________________

Email: ___________________________________

Why are you interested in lash extensions?
 
Do you know anyone who has had lash extensions? _____________________

Do you know anyone who has Nouveau Lash extensions? ________________

Where did you first learn of Nouveau Lashes? _________________________
 
When do you want to have the procedure done? _______________________

Please read the following statements:

    * Nouveau Lash extensions are made of a synthetic material, naturally cured to imitate your natural lashes
    * Eyelash tinting must be done prior to your Nouveau lash procedure
    * DO NOT PERM or CURL Nouveau Lash extensions
    * For two (2) days after Nouveau Lash treatment do not steam face, use steam bath, swim or wash face with hot water
    * Follow-up maintenance procedures may be required
    * The procedure is painless
    * The purpose of Nouveau Lash Extensions is to create the look of thicker, fuller and longer eyelashes
    * Only use water based mascara on the tips of the lashes
    * DO NOT use waterproof mascara or mascara eye makeup remover on Nouveau lashes
    * DO NOT rub eyes when washing face
    * Always pat dry lashes after cleansing
    * DO NOT use the sauna or a face steam everyday
    * You must not have any eye infection or irritation at the time of the procedure
    * Let your technician know if you have any allergies

 
 
Signature:_____________________                                  Date:_________
 
Technician Signature:__________                                  Date:_________