Christal Clear Beauty

Name

First Name

Last Name

Date of Birth

Phone

(###)

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How did you hear about us?

What would you classify your skin type?

What services are you interested in?

Brows

Lip Blushing

Freckles/ beauty mark

Eyeliner

When would you like to book, keep in mind the healing takes 7 days

Day 1-2 dark pigment. Day 3-4 pigment shedding. Day 7 completely healed. 2 weeks color is at its peak. Day 30 touch up in minor areas if needed. For best results, get a touch up for free with in 30-60 days from Day 1. Then wake up pretty!

Have you had permanent makeup in the past. If so, how long ago, how did you like your results, how long did it last? Is there any pigment left or any scarring caused from your past services? Please explain if you need a color correction.

You may leave this blank if it doesn't apply.

Do you have any medical conditions or immunity disorders? If no, please write N/A

Please check with your medial practitioner to make sure and confirm that there are no contradictions to your permanent makeup procedure. Please confirm with your medical practitioner prior to your procedure.

Check mark any and all medical conditions:

If you have no medical conditions, check mark "None".

HIV/ AIDs

Herpes

Hemophilia/ Bleeding disorder

Diabetes

Pregnant / Breastfeeding

Epilepsy

Cardiac Valve Disease

Taking Blood thinners: Aspirin, Coumadin, Alcohol, Ibuprofen

None

Are you currently undergoing any medical treatments or taking any medications that may affect your skin's healing or increase your risk for complications with permanent makeup? If no, write N/A

Currently receiving or have received cancer treatment. If so, I advise you to speak to your current medical doctor and ask when it is safe fore this procedure.

Current Medications. If none, fill in N/A:

Please type N/A if you do not take any medications.

Have you taken antibiotics prescribed prior to past dental or surgical procedures? if you opt out of lip blush for now, please fill in N/A

This is important mostly for lips as if you have ever had a cold sore, there are chances of infections. You can ask your doctor to prescribe you medication to start 5 days prior to service and continue 5 days after service. A herpes outbreak can lead to lip blushing failure and will not have the best results. If you have option

Do you have any allergies to topical salves such as Bacitracin, Lanolin, Lidocaine, Novocain, Metals, Neosporine, Papa, Rubber gloves, Latex, Epinephrine, Tetracaine, Benzocaine? If Yes, please explain. If no, please fill in N/A.

Please list any know allergies.

Have you ever had an allergic reaction to makeup or tattoo ink? If yes, please specify or note N/A.

Do you have any existing skin conditions or infections in the area where you want permanent makeup applied? If no, please fill in N/A.

Have you had any cosmetic procedures on the area where you want permanent makeup applied, such as Botox or chemical peels, in the past 4 weeks?

You can leave this blank if it doesn't apply. If it does apply, please write in the dates of procedures most recent.

Have you had any history of keloid scarring, abnormal wound healing, or bleeding disorders? If so please explain or write N/A.

Are you pregnant or breastfeeding?

Are you on any acne medications such as Accutane? Or use any products to control acne. Please list or fill in N/A.

I understand that it can take up to 4-6 weeks for my brows to fully heal. I understand a touch up is free with in 30-60 days for optimal pigment retention.

Yes

I understand that PMU can last 1-4 years and will lighten depending on my skin type and skincare regimen.

Yes

I understand and will follow the preparation for my PMU Services and After care services. Please type: YES

- Do not Make Social plans the first day of appointment. Note that brows will be dark 2 days and shed a few days after. - Do not bring a guest with you to your appointment. - Do not take aspirin or ibuprofen 3 days prior to your appointment. - Do not during alcohol and coffee 24-48 hours before your procedure. - Do not use AHA/ Retin-A skincare products 1 month prior and after to the area you will have procedure. - Do not tan two weeks prior or sunburn face after procedure. - Do not have any type of facial 2 weeks prior to your treatment. - Do not take fish oil, vitamin E on week prior as these will thin your blood. - Eyebrow washing should be performed no less than 3 days prior to your enhancement. - Do not have botox or fillers with in 3-4 weeks of your enhancement. - IPL laser hair removal should be performed no less than 2 weeks prior to your enhancement. - Electrolysis treatment should be performed no less than 5 days prior to your appointment. - Procedure must be scheduled at least 1 year after Chemotherapy unless you have a doctor note with explanation. - Do not work out for 48 hours after procedure. - Eye brow timing should not be undertaken for 2 weeks after your enhancement, however you will no longer need this. - No peels or exfoliants for a minimum 14 days. Strong chemicals/ glycolic acid/ peels of any kin will lift and lighten pigment. - Additional treatments cannot be undertaken until the area has completely healed. 4-6 weeks. Type YES below to complete the form.

I understand that it is $100 non refundable deposit to hold my schedule service date.

You may pay on my website or Venmo once we secure your booking date. The first initial visit is 3 hours. Touch ups is 1.5 hours at the most. If you want two services, it can take up to 5 hours long. We spend a full hour numbing, mapping and the services its self takes about an hour or so. If you do two services, I give restroom breaks between services. Please let me know if you need any special accommodations with assistance.

$100

By typing my name below, I understand that the application of permanent makeup involves a tattooing process and is not without risks. I have disclosed all relevant medical information to the best of my knowledge. I understand that individual results may vary, and I accept the potential risks associated with permanent makeup application. Consent and Agreement Signature:

Signed Date

This form is strictly confidential and will be used solely for the purpose of providing safe and appropriate permanent makeup services. The information provided will be kept securely and will not be disclosed to any third party without your consent.

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Christal Clear Beauty PMU - Permanent Makeup