Medical History & Consent • About Face And Body

Medical History

The following confidential medical information will be property of About Face And Body (About Face Ink LLC.) This information is required for the benefit and safety of the client. Please read and fill out the information carefully. We hope your experience will be a pleasant one and we thank you for your cooperation.

Name

Appointment Date

Birthdate

Age

Address

Email

Phone Number

Emergency Contact

Phone Number

Are you currently under the care of a doctor for a specific medical condition? Yes No

Physician Name

Phone Number

Would you like to be informed of any specials, discounts or events in the future? Yes No

Are you interested in any lash growth products? Yes No

Do you have a daily skin-cleansing regimen? Yes No

Are you interested in any anti-aging products or procedures? Yes No

A high-quality sunscreen not only protects your skin from sun damage but also prevents hyperpigmentation (darkening) during the phases of healing and provides longevity to any area exposed to the sun.

Are you interested in purchasing a high-quality sunscreen? Yes No

Please answer the following questions honestly to avoid complications :

Are you pregnant, nursing, or lactating? Yes No

Do you menstrate? Regular Heavy Menopausal N/A

If yes, next cycle date?

Do you intentionally tan? Yes No

If yes, how often?

Do you use Asprin or other blood thinners? Yes No

If yes, what do you use, and how often?

Do you have Diabetes? *If yes, you may heal a little slower and require more sessions than most people. Yes No

Do you need to be pretreated with medication prior to invasive procedures, or going to the dentist? * If yes, please contact your doctor to receive the required medication. Yes No

Do you use tobacco products or vape? (Smokers tend to heal slower. This will affect the timing of your follow up appt.) Yes No

If yes, what do you use, and how often?

Have you taken any form of mood-altering medication in the last 12 hours, i.e., Xanax, Marijuana, etc.? Yes No

If yes, what did you use, and when?

Have you consumed any alcohol in the last 12 hours? (This will make you more sensitive and potentially bleed more.) Yes No

If yes, what did you use, and when?

Are you currently experiencing active acne? Yes No

If yes, are you receiving professional treatment to manage it? Yes No

If yes, please explain:

Do you have a history of skin diseases? Yes No

If yes, please explain:

Are you under dermatological treatment for any reason? Yes No

If yes, please explain:

Do you typically heal slowly, or have complications with healing? Yes No

If yes, please explain:

Do you have any permanent makeup or tattoos? Yes No

If yes, did you have any complications with the healing process?

Are you currently undergoing radiation or chemo therapy? Yes No

If yes, please explain:

Do you have any allergies to metal? Yes No

If yes, please explain:

Do you have any allergies to products containing “caine?” i.e., Lidocaine etc. Yes No

If yes, please explain:

List all medications, both prescription and over-the-counter that you currently use.

List all nutritional supplements you currently use.

List any anti-inflammatory steroids, or immunosuppressive medications you currently use.

List any known allergies to petroleum-based products, topical antibiotic Polysporin, Bacitracin, or Neosporin.

If you have history of any of the above, please describe in detail for each.

Eyebrows Procedures Only

If you selected any of the above, please explain what and when.

Have you been in the sun for a pro-longed period in the last 7 days? Yes No

Do you exfoliate your skin at home? Yes No

If yes, what do you use and how often?

Do you have a personal history of skin cancer? Yes No

If yes, when was your last checkup with your doctor?

If yes, did you have surgery to remove the cancer? Yes No

If yes, what is the date of your last surgery?

Has the condition of your skin changed over the last two years? Yes No

Do you protect your skin daily with sunscreen? Yes No

Applying a high-quality sunscreen to your eyebrows will keep the area moisturized and lengthen the time between maintenance sessions. Your technician will recommend a sunscreen with a minimum of SPF 30+, which will be available for sale. If you choose to use a different sunscreen, please bring it with you so they can review the list of ingredients. I understand that consistent use of a high-quality sunscreen may make a significant impact on my healed results and lengthen the time between maintenance sessions. I agree that it is my responsibility to purchase a good sunscreen, and follow the instructions provided my technician. I understand that every person’s skin is unique, and About Face And Body and its practitioners cannot predict how my skin may react to the procedure. When pigments are used, it is possible the color may not heal consistently. I further understand that it is normal for the healed color to change because of my unique skin undertones. I also realize that About Face And Body and its practitioners cannot predict how many visits it will take to complete my procedure.

Eyeliner Procedures Only

Are you using any lash growth products? Yes No

If yes, what brand, and how long have you been using this product?

If yes, did you discontinue use of the lash growth product for at least 2 weeks prior to procedure? Yes No

Do you wear contact lenses? (If yes and you are undergoing an eyeliner procedure, they must be removed before the procedure and remain out for a minimum of 24 hours following your procedure.) Yes No

Do you have an eye condition known as Dry Eye? Yes No

If yes, do you use prescription medication to treat dry eye? Yes No

Do your eyes have noticeable veins on the whites of your eyes? Yes No

Do you have Glaucoma? Yes No

If yes, please request written clearance from your eye doctor and submit a copy below.Photos only (JPG, PNG or HEIC).

Do you plan to have a Blepharoplasty in the future? (Blepharoplasty is a surgery that repairs droopy eyelids.) Yes No

Do you have Ocular Herpes? Yes No

Consent: I understand that every person’s skin is unique, and About Face And Body and its practitioners cannot predict how my skin may react to the procedure. When pigments are used, it is possible the color may not heal consistently. I further understand that it is normal for the healed color to change because of my unique skin undertones. I also realize that About Face And Body and its practitioners cannot predict how many visits it will take to complete my procedure.

Lip Procedures Only

Have you ever had a cold sore, fever blister, or prior history of herpes?
Yes No

IF YES, contact your physician for a prescription of ZOVIRAX or some other anti-viral medication. Use medication 1-2 days before your service.

I have read the above information regarding an anti-viral medication and understand its use is mandatory for lip line or full lip color procedures.

Microneedling Only: Face & Neck

I wish to begin a series of treatments on the following area/s:

If you selected any of the above, please explain what and when.

Do you exfoliate your skin at home? Yes No

If yes, what do you use and how often?

Do you have a personal history of skin cancer? Yes No

If yes, when was your last checkup with your doctor?

If yes, did you have surgery to remove the cancer? Yes No

If yes, what is the date of your last surgery?

Has your skin changed over the last two years? Yes No

Do you use sunscreen every day? Yes No

It is very important to protect your face and neck from the sun, especially during the first 8 weeks of healing after a treatment. Even 20 min of sun exposure can cause hyperpigmentation (darkening of skin as it heals.) Your technician will recommend a sunscreen available for sale. If you use a different sunscreen, bring the sunscreen with you so they can review the ingredients.

Have you ever had a fever or cold sore? Yes No

If yes, contact your doctor for an anti-viral medication. Depending on the recommended dose, start the medication the 1-2 days before, or the day of your service. Continue the medication for 1-2 days after your treatment. You will likely experience a cold sore breakout if you do not use medication.

Which of the following best describes your skin type? I. Always burns, never tans II. Always burns, sometimes tans III. Sometimes burns, always tans IV. Rarely burns, always tans V. Brown, moderately pigmented skin VI. Black skin

Consent: I understand that if I am a skin type V and VI, I am at a higher risk for hyper-pigmentation and hypopigmentation than other skin types. I agree to the risk involved. I understand I should use a high-quality sunscreen daily. I understand that if I am prone to cold sores, it is my responsibility to use an anti-viral medication. I understand that microneedling induces the production of new collagen. The needles penetrate the epidermis (top layer of the skin) and cause micro injuries. The body releases healing factors that lead to the formation of new collagen and elastin fibers. This is beneficial to wrinkles and scars. I understand that redness and swelling may occur, and last for 1-2 days. I understand the following risk exists: Keloids; Hyperpigmentation (Consistent use of SPF 30+ sun protection can prevent this); Activation of a cold sore around my lips if I have a history of it I understand that microneedling typically requires a series of treatments. Depending on my goals, the age of my skin, and my desired result, 3-6 treatments may be needed.

Name of Dermatologist:

Phone Number

Name of Aesthetician:

Phone Number

Tattoo Lightening/Removal Only

Location of the tattoo on your body:

How old is the tattoo?

Name of technician/facility:

How many times was it tattooed?

This pigment is unwanted because: shape color location

I would like my technician to attempt to: remove the tattoo if possible lighten the tattoo remove a portion of the tattoo

Are you allergic to any type of salt? Yes No

Are you allergic to citrus (orange or lemon)? Yes No

Are you allergic to Aloe Vera? Yes No

Have you had a chemical peel in the last two weeks? Yes No

Do you protect your skin daily with sunscreen? Yes No

The treatment area will form a scab. The scab must fall off naturally. Once the scab is gone, it is very important to protect the area from the sun during the first 8 weeks of healing. Even 20 min of sun exposure can cause hyperpigmentation (darkening of skin as it heals.) Your technician will recommend a sunscreen with a minimum of SPF 30+, which will be available for sale. If you choose to use a different sunscreen, please bring it with you so they can review the list of ingredients.

Which of the following best describes your skin type? (Please select one number) I. Always burns, never tans II. Always burns, sometimes tans III. Sometimes burns, always tans IV. Rarely burns, always tans V. Brown, moderately pigmented skin VI. Black skin

Scars, Areola Tattooing, & Stretch Marks Only

Have you received treatment for this concern before contacting About Face And Body? Yes No

If yes, what treatments or procedures have you used and when did you have them done?

What is your desired goal for this area of concern?

Do you protect your skin daily with sunscreen?

If applicable:

If the treatment area receives regular exposure to the sun, it is very important to protect it with daily with sunscreen during the first 8 weeks of healing. Even 20 min of sun exposure can cause hyperpigmentation (darkening of skin as it heals.) Your technician will recommend a sunscreen with a minimum of SPF 30+, which will be available for sale. If you choose to use a different sunscreen, please bring it with you so they can review the list of ingredients.

Do you have a personal history of cancer (any type)?

If yes, what type of cancer?

Have you had elective or non-elective surgeries in the past year? Yes No

If yes, list when, and type of surgery.

Consent: I understand that every person’s skin is unique, and About Face And Body and its practitioners cannot predict how my skin may react to the procedure. When pigments are used, it is possible the color may not heal consistently. I further understand that it is normal for the healed color to change because of my unique skin undertones. I also realize that About Face And Body and its practitioners cannot predict how many visits it will take to complete my procedure.

If my treatment area receives regular exposure to the sun, I understand the following will apply: Consistent use of a high-quality sunscreen. Using sunscreen does not guarantee hypopigmentation will not occur, but it reduces the chances dramatically. If my treatment involves using ink to camouflage the area exposed to the sun, sunscreen will not be recommended initially, but it IS recommended for the longevity of the scar camouflage.

Breast Cancer Clients Only

What type of surgery did you have? Bi-lateral Uni-lateral

What is the date of your last surgery?

Did you receive radiation on one of your breasts? Yes No

If yes, which side?

Do you have breast implants? Yes No

Do you expect to have any further procedures related to reconstruction or revision of your breasts, including fat injections? Yes No

If yes, please explain.

Are you currently undergoing radiation or chemotherapy? Yes No

If yes, please explain.

Policy Acknowledgement, Consent, Authorization and Medical Release

I, , recognize and acknowledge that I will be given the full opportunity to ask About Face And Body and its practitioners any and all questions about cosmetic tattooing procedure(s), its process, and the risk involved. I also acknowledge that my questions will be answered to my full and total satisfaction. I confirm that the decision to have cosmetic tattooing procedure(s) performed is my own.

A deposit is required at the time of booking and applies to the cost of your service.

We understand that extraordinary circumstances happen, and you may need to change your schedule. We kindly ask that you give us a minimum of 3 business days’ notice for canceling or rescheduling an appointment. This notification enables us to schedule another guest, and, in turn, maintain a higher availability for you as well as other clients in the future.

If you cancel your appointment and 3 business days’ notice is not given, you will forfeit your deposit. Late cancellation, or missing your appointment will not only forfeit your deposit, but an additional $100 missed appointment fee will also be charged to the card on file. Full payment of service will be required prior to rescheduling a new appointment. Late cancellations, rescheduling and "no shows" leave gaps in our schedules that cannot be filled without timely notice.

Because every client's experience is important to us, we ask that you arrive on time. If you are running more than 15 minutes late, please communicate that with us, and we will let you know if we can accommodate you. In the event we cannot, you will forfeit your deposit, and a new deposit will be required to reschedule.

CDC and OSHA guidelines do not allow observers in the procedure area during the procedure process. Absolutely NO children, including infants in carriers, may be present at the appointment. We are mothers and love children, but this is not an appropriate time to have children present. If you bring a child with you, full payment of service will be required prior to rescheduling a new appointment.

Communication is vital during your procedure. If English is not your first language and you need help communicating, please bring someone with you to assist in this communication. This person will need to be present for the entire procedure. If you do not bring someone with you and WE find it difficult to communicate, we will have to reschedule, and you will forfeit your deposit. A new deposit will be required upfront, before we reschedule you.

Many procedures are a multi-session process. A follow-up visit will be scheduled 4 - 8 weeks after the initial procedure and has an additional fee associated. Follow-up visits must be completed no more than 12 weeks from the initial procedure. A quote will be provided based on the timeframe recommended. Failure to complete the follow-up within 12 weeks will result in a higher fee for that appointment.

We are in our studio by appointment only so we cannot accommodate walk-ins. If you are interested in meeting us in person, we would be happy to spend time with you, but ask that you schedule a consultation.

Procedures on the skin are not an exact science. There are various skin types and undertones. Some areas of the skin have experienced trauma. Therefore, results cannot be guaranteed. Absolutely no refunds will be given for any procedure.

***Areola Tattooing/Insurance Billing only: I understand that About Face And Body requires either payment of the rate agreed upon or a non-refundable administration fee of $150 before submitting an invoice to my insurance company. I understand the $150 fee applies to the cost of my procedure at the time of service. I acknowledge that the policies above regarding proper cancelation notice and missed appointments still apply and are separate from the $150 administration fee.

By signing this consent form, I confirm that I have read and understand each paragraph above and specifically agree to be bound by its contents thereof.

Signature

Date

Take advantage of our quick and easy pre-consultation form.

cosmetic + medical tattoo specialists

Service Forms
Financial Assistance
Blog + Articles
BROW STYLES
Reviews
Our Portfolio
FAQ

Our Story
Meet the Team
Train with AboutPMU
Our Certifications
Announcements
Our Location

Permanent Makeup
3D Areola Tattoo
Scalp Micropigmentation
Scar Revision + Camouflage
Stretch Mark Treatment
Skin Treatments
Tattoo Removal

Take advantage of our quick and easy pre-consultation form.

cosmetic + medical tattoo specialists

Service FormsFinancial AssistanceBlog + ArticlesBROW STYLESReviewsOur PortfolioFAQ

Our StoryMeet the TeamTrain with AboutPMUOur CertificationsAnnouncementsOur Location

Permanent Makeup3D Areola TattooScalp MicropigmentationScar Revision + CamouflageStretch Mark TreatmentSkin TreatmentsTattoo Removal

Service Forms
Financial Assistance
Blog + Articles
BROW STYLES
Reviews
Our Portfolio
FAQ

Our Story
Meet the Team
Train with AboutPMU
Our Certifications
Announcements
Our Location

Permanent Makeup
3D Areola Tattoo
Scalp Micropigmentation
Scar Revision + Camouflage
Stretch Mark Treatment
Skin Treatments
Tattoo Removal