Todays Date:   

Name:   

Date of Birth:   

Ethnic Background, please include all nationalities:   

Address:   

City:

State:   

Zip:   

Home Phone:  

Cell:   

Occupation:   

If we call you at home, do you want confidentiality?

May we call you at work?

If Yes, my work number is:   

Emergency Contact, Name:  

Phone:   

Relationship:   

Who may we thank for referring you?   

Procedure(s) desired:

List all medications you are presently taking:

Name of drug prescribed to you,  Mg. or mcg. , How many ea. day ,Why it was prescribed to you

List all medications you took in the last six months that you are no longer taking:

Name of drug prescribed to you,  Mg. or mcg. , How many ea. day ,Why it was prescribed to you

Do you have? (check all that apply)

If you checked any, please explain:

Are you? (check all that apply)

If you checked any, please explain:

Do you use? (check all that apply)

If you checked any, please explain:

Have you had? (check all that apply)

If you checked any, please explain:

Do you practice outdoor activities? Circle all that apply

Physician’s Name:  

Address:  

INFORMED CONSENT TO PROCEDURE

1. Are you pregnant or nursing?

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. 

3. I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them. 

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.

5.    I understand that the color selection and color results in all procedures are not an exact science. 

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.  

7. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics.  

8.   If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.

9.  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. 

10.  I realize this is an elective cosmetic procedure and is not medically necessary. 

11. 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. 

12. 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.  

13. I give my consent to Ms. Fitz Glitz and Glamour to confer with my physicians for medical information required for the safety of my procedures.  

14. 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. 

15. 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.    

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. 

**Please read all questions thoroughly before signing!!

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Signed by Tara Fitzgerald
Signed On: July 15, 2018

Signature Certificate

Document name: Client Information and Consent Form

Unique Document ID: 8b10f823d3146dd0458538f9bd7013802530d2a9

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Timestamp	Audit
April 2, 2018 6:20 am GMT	Client Information and Consent Form Uploaded by Tara Fitzgerald - tara.fitzgerald3@aol.com IP 24.251.236.133

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