Pre-Procedure Questionnaire

Have you had any permanent make up, previously?
If YES, I will need to know that you have not been tattooed with Premier True Concentrates between the years 2000 and 2004. If you have, I will require written documentation from your previous practitioner that this product was not used. The Premier pigment described can trigger an allergic reaction.
If you have had previous permanent makeup procedure, please describe the color that is remaining so I will know whether you need a touchup or correction.
Are you pregnant or nursing? If YES, please reschedule your appointment after your delivery and or nursing.  
Are you scheduled for or considering vision correction surgery? No procedures can be performed 1 month prior to laser surgery and 3 months after.  
Have you recently had facial surgery ~ Botox ~ fillers such as Restalyne, Sculptra, etc. ~ any type of lip augmentation? If YES, there may be a waiting period.  
Are you on Blood thinners such as Coumadin, etc. ~ Steroids such as Prednisone ~ Chemotherapy ~ Prophylactic Chemotherapy. If YES, medical clearance will be necessary.  
Are you on Accutane for treatment of Acne? If YES, a waiting period of 1 year is necessary prior to permanent cosmetics  
Do you have heart valve replacements, stents, ~ Mitral Valve Prolapse ~ Rheumatic Fever or any heart condition? If YES, they may need to be pre-medicated.  
Are you pre-medicated prior to dental work? If YES, they may need to be pre-medicated.  
Have you ever had an organ transplant? If YES, you are not a candidate.  
Do you have joint replacement? If YES, you will require pre-medication and medical clearance.  
Are you an insulin dependent diabetic? If YES, medical clearance is required.  
Do you have any dermatologic disorders such as Shingles, Rosacia, Eczema, and Psoriasis and are they active? If YES or they are active, they must wait until they have calmed down.  
Do have any medical condition that has you presently in the care of a doctor or believe? If YES, they may need medical clearance.  
Do you plan on going on a vacation (in the sun) in the next 2 weeks? If Yes, you may need to reschedule and discuss sun protection options (hat, sunglasses and sunscreen).

All permanent cosmetic procedures are multi-session processes. You are required to come back for at least one touchup visit before it can be determined that your work is complete. Touchup visits are scheduled approximately 4 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, (1 to 2 weeks for brows and eyeliner. Six weeks for lips) based on how quickly the outer layer of your skin exfoliates.

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 2 weeks healing from time of procedures for significant events. This reduces stress for all.

Do not wear makeup on the day of procedure but do bring your lip or brow pencils to the office on the day of the procedure as well as reference photos.
 

Eyebrow Procedures

How much hair do you have in your brow? Any eyebrow tinting should be done no sooner than 48 hours before or two weeks after the procedure.

Lips Procedures

Do you have a fever blister, at this time, or have you ever had even one fever blister in your lifetime? If you are having lip procedures and have any history of cold sores/fever blisters/herpes simplex, you will be required to contact your physician for Valtrex to possibly prevent such outbreaks. Many physicians prescribe 12 capsules of 500 mg. Valtrex. Your physician may prescribe that they be taken twice a day, two days before lip procedures and four days after. Be sure to ask for 24 to avoid 2 copays. This will include enough medication for your touch up visit.  

Eyeliner Procedures

Do you wear false eyelashes or eyelash extensions? If Yes, must be removed before eyeliner procedure. Reapply after 2 weeks post procedure.  
Do you use Latisse®? If yes, discontinue using at least 1 week prior to eyeliner procedure. Resume Latisse® 2 weeks post procedure. If you are a long term eyelash serum user a longer rest period of a month is mandatory to prevent excessive bleeding and possible pigment migration.  
Any eyelash 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.  

Areola Pigmentation

Medical clearance on a letterhead or prescription note will be required.  If the area to be treated includes scars, the minimum waiting time is 8 months from last revision on the area.  


Camouflage Procedures

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.

Intake Questionnaire

First Name*
Last Name*
Email Address*
Date of Birth*
Ethnic Background, please include all nationalities
Complete Address
Home Phone
Cellphone
Occupation
If we call you at home, do you want confidentiality?
May we call you at work?
If Yes, If Yes, what is your work number?
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Who may we thank for referring you?
Procedure(s) desired
Name of Drug, Mg. or mcg., How many each day, why it was prescribed to you. [A] List all medications you took in the last six months that you are no longer taking
Name of Drug, Mg. or mcg., How many each day, why it was prescribed to you. [B]
Please upload at least one (1) photo. You may upload additional photos using the "Upload a File 2" and "Upload a File 3" fields. Permitted file types: jpg, jpeg, png, gif, bmp.

Photo Guidelines: Please make sure your uploaded photos adhere to the following guidelines: no makeup, photo(s) must be taken in bright light with good image resolution, appropriate closeups are needed for eyes, and appropriate closeups are also needed eyebrow and lip procedures.
 


Upload a File 1*
Upload a File 2
Upload a File 3

General Medical Questionnaire

Do you have Fever Blisters/Cold Sores?
Do you have Glaucoma or other eye disease/disorder?
Do you have Grave's Disease?
Do you have Heart Disease?
Do you have Mitral Valve Prolapse?
Do you have Valve Implants?
Do you have a Pacemaker?
Do you have Stents?
Do you have Diabetes requiring insulin?
Do you have Problems with healing?
Do you have Keloids?
Do you have Seizures?
Do you have a Dermatological Disorder?
Do you have Hemophilia or Clotting Disorder?
Do you have an Autoimmune Disorder?
Do you have a Pre-existing nerve damage?
Do you have Tattoos?
Do you have Trichotillomania (pulling of hair, brows, lashes)?
Do you have Alopecia Totalis or Areata?
Do you have Allergies?
Do you use Accutane (currently or within past year)?
Do you use Antibiotics prior to dental procedures?
Do you use Steroids?
Do you use Retin-A, Glycolic Acid, Vitamin C or other Exfoliants?
Do you use Tanning Beds?
Do you use Eyebrow Tinting?
Do you use Eyelash Tinting?
Do you use Latisse?
Do you use Botox and when?
Do you use Chemical Peels and when?
Do you use Chemotherapy or Prophylactic dose of Chemotherapy?
Do you use Blood Thinners?
Are you Pregnant?
Are you Planning cosmetic surgery?
Are you Currently under the care of a physican?
Have you ever had Fever Blisters/Cold Sores?
Have you ever had Eye Infections (are you prone to them)?
Have you ever had Vision Correction Procedure (Lasik, RK) within the past 3 months?
Have you ever had a Heart Attack and when?
Have you ever had Joint Replacement, Organ Transplant?
Have you ever had Eye Trauma?
Have you ever had Seizures?
Have you ever had Fainting Spells?
Have you ever had Hepatits and what type?
Have you ever had Hepatitis Test and when?
Have you ever had Fat Transfer Injections and when?
Have you ever had Gore-Tex Implants and when?
Have you ever had Aesthetic or Cosmetic Procedures and where?
Have you ever had Laser Treatments, what type and why?
Do you participate in any sport or outdoor activities? ex: swimming, golf, tennis, gardening, etc

Physician Information

Physician's Name
Physician's Complete Address
Physician's Specialty

Informed Consent

1. 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.

2. 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.

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

4. 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.

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

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

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.

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

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.

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 cosmetics.

11. I give my consent to Avarte to confer with my physicians for medical information required for the safety of my procedures.

12. 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.

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.

14. If I had permanent cosmetics performed previously by another practitioner, I do not hold Avarte responsible for future allergic reactions or contraindications.
 

15. By initialing this I release all rights to any pre and post procedure photographs and give consent in advance to their reproduction in print or electronic form for marketing and educational purposes. I understand ONLY the procedure areas will be used for this purpose and my identity will be held confidential unless a full model disclosure form is discussed, signed and agreed upon by myself and Avarte. (If you do not initial this provision, please advise your Artist)

16. I waive all responsibility to my practitioner and Avarte, and I assume full responsibility that I can see to drive, perfectly. 

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

Policies:

 

All procedures consist of two visits. Touch-up after initial procedure must be performed within the first 3 month period following the procedure.
If Client fails to contact and have the practitioner asses the procedure within the initial 3 month period and requests a touch-up within a year’s time, the cost will be half the total price of procedure Any requests after a year has passed without prior contact and procedure assessment, will result in full current cost of procedure.

We strive to provide the best quality workmanship and proper assessment after a procedure is needed in order to achieve the best results, without us evaluating the healing process it voids any included touch-up costs.

       

**Yearly touch ups consist of ONE visit only and are billed at 50% original cost for the first 2 yrs and 50% current cost thereafter.

 

Please Note:

 

$100 Deposit is to be secured on all procedures.

Deposit to be applied towards procedure at appointment date but Non-Refundable in the event of late cancellation.

All cancellations and Rescheduling require a 72 hr (3 day) notice.

A no show to an appointment will forfeit the deposit and any future appointments will require full payment in advance to book.

With locations in New Jersey and Florida, please be advised a Strict Cancellation Policy must be enforced in order to service all clients in multiple locations fairly.

We accept cash, credit cards, money orders and personal checks. All services must be PAID IN FULL on the procedure day. Returned checks will result in a $45 fee. Any and all additional expenses incurred by us in order to collect on a bad check will be the responsibility of the client. Absolutely no refunds nor credit after services have been rendered. 

If prior permanent makeup was performed by another practitioner, a signed release form will be required.

With the understanding that a dire emergency may arise, please be advised that arriving 15 min late will result in rescheduling and loss of deposit, respecting all of our clients time is our upmost priority. Due to the nature of the services we offer, there are policies that need to be followed in order to have a relaxed, satisfactory and enjoyable experience for all.  In special cases, and when our schedule will allow, we may be able to accommodate the appointment. This will be at our discretion and only with advance notification only.

 

Please note no one is allowed in the procedure room except for the client and practitioner.  Please be advised if bringing children they must be chaperoned at all times by an adult.



ACCEPTANCE:

I have read and understand these risks listed above and they have been explained to me. I DID NOT JUST SIGN THIS DOCUMENT. I certify that the information in the above questionnaire is accurate and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request.


Yes, I consent to all*
click to consent
 
Client Signature (please sign with mouse, stylus, or finger)

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