INTAKE FORM & MEDICAL INFORMATION

Name

Today’s Date:

Address:

Emergency Contact Name:

Emergency Contact #:

YOUR DOB:

Cell Phone:

Home Phone:

Referred By:

ID Type & Number:

Photo Authorization:

I consent to have all consultations/procedures recorded by video and/or photograph. I understand the footage may be used for training and promotional purposes. I understand I can opt out of all public footage by checking this box

Client Signature

Date

Acknowledgement of Service Definitions and Rates for Future Services

Payment, Cancelations, and Refund Policies

I agree that this transaction is final, no substitutions, exchanges, or refunds. I understand that for whatever reason I change my mind and decide not to obtain all sessions I paid for there is a no money back guarantee. I understand cancelling appointments within 72 hours or not showing will result in the forfeit of my booking deposit. Not showing 2 times in a row will result in the cancellation of the remainder of my appointments. I understand if I am more than 10 minutes late for an appointment and there is not enough time remaining in the schedule to complete the procedure, it will result in the forfeit of my deposit and require me to reschedule my appointment with a new booking deposit.

Company Policies

I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s). I consent to have all consultations and procedures recorded by photograph and/or video as part of my permanent office record. Such video and photos shall be destroyed from time to time as part of routine records management. I understand that Beautiful by Design, LLC / DBA BeYOUtiful Ink is under no obligation to share with me my before and after photos/videos. I am aware that I am allowed to take my own before and after photos with my own camera/cell phone for my personal use. For the purposes of training, education or assistance, I consent to the admittance of authorized observers to the procedure(s) I, as the client, hereby acknowledge that the provider herein maintains the right to refuse service or any future service to any client or customer. If a situation arises whereby the provider terminates our relationship, the parties agree to peacefully and cordially discuss any potential refunds or terms of separation to minimize the harm to either party.

How long has it been since you last ate?

Informed Consent/Assumption of Risks Cont.

I am aware that permanent makeup is a layering process and there is no way to predict with certainty how my skin will heal. The outcome varies from person to person in the following ways (but not limited to):

Permanent makeup may last anywhere between 1-3 years.
Permanent makeup will soften/fade in color over time.
Environmental factors such as individual lifestyle, sun exposure, or the use of anti-aging creams and/or tanning beds can promote fading.
My skin type and/or condition will affect the overall result of my procedure. (i.e., large pores, oily skin, or Rosacea are typically not ideal for microblading.)
Brows with previous permanent makeup may not be able to attain hair stroke brows because the previous pigment(s) and/or lines will continue to surface.
Failure to adhere to pre- and post-procedure instructions will jeopardize my chances for a successful procedure.
The actual color of the pigment may be modified slightly due to the tone and color of my skin.

I understand that receiving future additional treatments or skin-altering procedures may cause adverse changes to my permanent makeup and that:

Such changes in my appearance may or may not be correctable.
Such changes are not the fault of Beautiful by Design, LLC / DBA BeYOUtiful Ink or Kelly Yetzer.

Additional Services Warning

Additional services that may cause adverse changes include, but are not limited to:

Laser Treatment
Laser Hair Removal
Plastic Surgery
Implants
Injections

I acknowledge that it is recommended to get color boost services periodically to maintain the appearance of my permanent makeup and that:

My Artist has the right to decide whether additional touch-ups are necessary.
My Artist may recommend an alternate technique that may be better suited to my skin type at subsequent sessions. For example, my Artist may recommend a change from microblading to powder brows.

I understand the restrictions associated with this body art procedure as explained by my technician.

I request a patch test. (If I am requesting a patch test I understand the cost is $50 and it must be done 14 days prior to my scheduled appointment. If I request a patch test at the time of my service it will be an additional $50 and I will forfeit my deposit. I will be sent home and understand a new deposit will need to be paid in order to book a new appointment.)

I waive the patch test.

Cont.

I accept the risk that there is a possibility of an allergic reaction to pigments, dyes, numbing creams, topical preparations, and/or processes used in permanent makeup procedures. I also acknowledge that a patch test:

Is advisable but does not ensure that I will not have an allergic reaction.
May be requested prior to beginning my procedure.
Will delay my permanent makeup procedure until I can show that the impacted area is fully healed without adverse reaction.

I release the Kelly Yetzer and Beautiful by Design, LLC / DBA BeYOUtiful Ink from liability if I develop an allergic reaction to any materials or processes used in the procedure.

I am aware of the signs and symptoms of infection, including, but not limited to, redness, swelling, tenderness of the procedure site, red streaks, going from the procedure site towards the heart, elevated body temperature, or purulent draining from the procedure site

I understand there is a possibility of getting an infection as a result of receiving body art / cosmetic tattoo. I will seek professional medical attention, if signs and symptoms of an affection occur.

The nature and method of permanent makeup procedures have been explained to me, and I understand that permanent makeup procedures may have the possibility of complications or consequences including, but not limited to:

Infection
Scarring
Inconsistent Color
Asymmetry
Spreading, Fanning, Fading, or Loss of Pigment
Minor and Temporary Bleeding, Bruising, Redness, or other Discoloration
Swelling, Fever, and/or Blisters

I understand that such occurrences are rare when the affected area is properly cared for and post-procedural instructions are followed. Having been fully informed about the risks inherent in this procedure, I understand and agree voluntarily to assume all known risks inherent in such procedure.

I agreed to follow all instructions concerning the care of my body are procedure, and that any touchups needed due to my own negligence, will be done at my own expense.

Informed Consent/Assumption of Risks Cont.

Cont.

At the time of signing this consent, I am of sound mind, capable of making independent decisions for myself, and acknowledge that:

I understand the content of this agreement and hereby acknowledge that this is a binding legal contract.
I have received no guarantees or warranties with respect to the benefits or results to be realized from, or consequences of, the aforementioned procedure(s).
Submitting to body art / cosmetic tattoo procedure(s) is of my choice alone, and I consent to the application, the procedure, its attendant risks, and any actions or conduct of the Artist reasonably necessary to perform the procedure(s).
I accept full responsibility for the decision to have this cosmetic tattoo work done.
The general nature of body art / cosmetic tattooing as well as the specific procedure to be performed has been explained to me in full.
I have been given the opportunity to ask any questions which I may have about obtaining any permanent makeup cosmetic procedures from Beautiful by Design, LLC / DBA BeYOUtiful Ink.
I understand the usual risks inherent in the procedure and the possibility of complications during and following its performance.
I acknowledge that all of my questions have been answered to my full and total satisfaction.

For Lip Procedures Only

I acknowledge that I was advised to obtain a prescription anti-viral medication from my physician before undergoing a Lip/MicroNeedle procedure. I waive the anti-viral medication that I was advised to obtain. I release the Artist and Beautiful by Design, LLC , LLC / DBA BeYOUtiful Ink, from liability if I have an adverse reaction to the Lip procedure.

I obtained an anti-viral medication from my physician. Check one please.

YES NO

For Eyeliner Procedures Only

I understand that corneal abrasions are a rare side effect of the eyeliner procedure, and that the chance or occurrence is greater if I rub my eyes or apply contacts too soon after any eyeliner procedure.

Medical Questionnaire

To avoid unforeseen complications, please indicate the appropriate answer to the following questions with an X:

Medical Profile

Have you had any permanent makeup procedures before Beautiful by Design, LLC / DBA BeYOUtiful Ink? If yes, please tell us what you have had done, how many times you’ve had it done and by which artist.

Are you allergic to topical antibiotic preparations or desensitizers? (e.g. Polysporin, Bacitracin, Neosporin or “Caine” family drugs or Petroleum)
Yes No

Are you required to take antibiotics during dental or invasive medical procedures?
Yes No

Do you have any history of cold sores, herpes, or fever blisters? (Ever in your life)
Yes No

Do you have problems with tattoos? Have you been advised not to have a tattoo?
Yes No

Are you currently undergoing chemotherapy or radiation therapy?
Yes No

Are you taking prescription medication? Please list here & include immunosuppressive, anti-inflammatory and steroid medication (if you filled out the pre-appointment questionnaire online do not add here):
Yes No

Have you had any aspirin or blood thinning products within the last 7 days?
Yes No

Have you had any mood-altering drugs in the last 8 hours or anti-depressant?
Yes No

Are you presently taking Vitamins A and/or E in any form?
Yes No

Are you currently using Retin-A or Alpha Hydroxy skin care products?
Yes No

Is there any history of skin diseases or remarkable skin sensitivities?
Yes No

Do you have problems with healing?
Yes No

Have you had a chemical/laser peel within the last two weeks?
Yes No

Do you have any fillers (Botox, Juvederm, etc.) within the last two weeks?
Yes No

Have you experienced withdrawal from caffeine products? Have you experienced withdrawal from caffeine products?
Yes No

Do you have lash extensions, or do you use Latisse or similar product?
Yes No

Are you allergic to any metal? (e.g. I can only wear 14K gold.)
Yes No

Do you wear contact lenses? If yes, please remove for eyeliner procedure and do not replace for 24 hrs.
Yes No

Are you sensitive to Latex?
Yes No

Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?
Yes No

Do you have any condition that requires you to take medication such as anticoagulants that thin the blood or interfere with blood clotting?
Yes No

Have you been prescribed antibiotics prior to dental or surgical procedures?
Yes No

Do you have any medical or skin conditions that might affect the outcome of this procedure?
Yes No

Do you have any cardiac valve diseases?
Yes No

Please check any of the following which pertain to you:
Alopecia Allergies to Makeup Accutane Treatment Autoimmune Disorders Cancer Chest Pains Diabetes Dry Eyes Epilepsy/Seizures Fainting Glaucoma Hair loss other than Alopecia Heart Conditions Hemophilia Hepatitis/Jaundice/HIV Kidney Disease Keloid Formation Keloid/Hypertrophy Scars Narcolepsy Ocular Herpes Refractive Eye Surgery Thyroid Disorders Trichotillomania Shortness of Breath Skin Lesions Stroke Skin Disease (psoriasis, eczema, etc.) Skin Sensitivity to soap or disinfectant Tendency to Bleed Excessively from Minor Injuries Tendency to Develop Fever Blisters on lips (cold sores) Hypo-Pigmentation (lightening of the skin) Hyper-Pigmentation (darkening of the skin) Vitiligo

Additional Health Information. Please explain any checked question, list any medications or other medical conditions:

Doctor’s Name

Phone Number

I have been fully informed of the risks of body art /cosmetic tattoo including, but not limited to infections, scarring, and allergic reactions to items associated with body art procedures. Technician will not perform the body art procedure if you fail to complete or sign this form. Further, technician may decline to perform a body art procedure if the client has any identified health conditions. Having been informed of the potential risks associated with this body art procedure, I still wish to proceed with the body art application, and I assume any/all risks that may arise from body art.

Client Name

Client Signature

Date

Technicians Name

Technicians Signature

Date

I have personally reviewed the above information with my client or the client’s representation.

PERMANENT MAKE-UP PATIENT PHOTO RELEASE AGREEMENT

Clients Name:

I hereby consent to, and authorize the use by Beautiful by Design, LLC / DBA BeYOUtiful Ink of the specified permanent make-up photographs and/or video; that is, photographs taken before, during, and after my permanent make-up procedure.

I understand that if I choose so, my identity will be protected, and neither my full face nor my name will be used in conjunction with the photographs and/or video.

Beautiful by Design, LLC / DBA BeYOUtiful Ink has explained that all the photos and/or videos will be clinically appropriate and tastefully presented.

I have agreed on the photographs that Beautiful by Design, LLC / DBA BeYOUtiful Ink has requested to be used, and it is understood that these photos may be used on Beautiful by Design, LLC / DBA BeYOUtiful Ink’s website, social media accounts (Facebook, Instagram, Pinterest, Twitter), and in-office for demonstration and promotional purposes. I understand that I am not entitled to compensation for the photos that are to be used.

Should I desire to revoke permission for their use in the future, I understand that I must notify Beautiful by Design, LLC / DBA BeYOUtiful Ink in writing and allow 30 days to accomplish this removal.

I now release Beautiful by Design, LLC / DBA BeYOUtiful Ink and anyone authorized by Beautiful by Design, LLC / DBA BeYOUtiful Ink, all personal rights and objections I have or may have to the above-described uses of my photographs and/or videos. I have entered into this release voluntarily and agree to be bound thereby.

DATE

PATIENT SIGNATURE

DATE

TECHNICIAN/WITNESS SIGNATURE