Client Forms

Permanent Cosmetic Forms

Please fill out and sign the following 3 forms:

1) Medical History

Today's Date *

Name *

First

Last

Cell Phone *

Alternate Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Referred By

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Emergency Contact Relationship *

Please answer these questions truthfully to the best of your knowledge

The answers to these questions will helps us ensure the best possible outcome for your treatment from Lisa Marie's Cosmetic Solutions.

Are you now or have you been under the care of a Physician within the last two years? *

If yes, please describe why and provide Physician name, address and phone number

List all medications you are currently taking, including Retin A, Glycolic Acid, Acutane, and/or Latesse *

List all drug, make-up, skin or food allergies *

Have you currently undergone a skin peel, laser treatment or light treatment? *

If yes, which one and when?

What products do you use for your skin care regimen? *

Do you have or have you had any of the following conditions? *

Abnormal Heart Condition
High or Low Blood Pressure
History of cardiac valve disease
Herpes Simplex (any history, no matter how many years ago, specifically at procedure site)
Cold Sores
Fever Blisters
Hemophilia or other blood disorders
Prolonged Bleeding
Circulatory Problems
Diabetes
Cataracts
“Dry Eye”
Eye Surgery or Injury
Visual Disturbances
Tumors/Growths/Cysts
Epilepsy
Fainting spells/dizziness
Glaucoma
Corneal Abrasion
Blepharoplasty
Cancer
Chemotherapy/Radiation
Hepatitis
A Pacemaker or major heart problems
Collagen Vascular Disease
Auto-immune Disease (ex: Lupus/Rheumatoid Arthritis)
Are you currently pregnant?
History of allergic reactions to latex
History of allergic reaction to antibiotics
Do you use tobacco products?
Do you drink alcohol?
Do you require antibiotics prior to surgery or dental procedures?
Any risk factors for blood borne pathogens?
Are you using any eye drops or other ocular medications?
Have you ever experienced hyper-pigmentation from an injury?
Have you ever keyloided from a injury?
Are you currently taking aspirin or ibuprofen?

Date of your last eye exam? *

Eye Examining Physician’s Name *

Signature

2) Disclosure & Consent

Today's Date *//

Name *

First

Last

Date of Birth *//

Cell Phone *

Email *

I, as a client, have requested that Lisa Marie Bates describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. *

True
False

Lisa Marie Bates has described the recommended procedure to be used as Micro Pigment implantation, the process of implanting micro insertions into the dermal layer of the skin. Micro Pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic make-up and skin imperfection camouflage. *

True
False

I voluntarily request as my Permanent Cosmetic Technician, Lisa Marie Bates and technical assistance as she may deem necessary to perform on my face and/or body the following procedure(s): *

I have informed Lisa Marie Bates that I am in good health and not under the care of any physician.

Yes I am not under the care of any physician
No I am currently under the care of a physician

If you answered NO, please list the condition(s) you are being treated for and your Physicians name, address and phone number.

I am 18 years or older.

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give my consent for this procedure.

Agree
Not Agree

I understand that no warranty or guarantees have been made to me as a result of my procedure.

Agree
Not Agree

I understand that there is a possibility of hyper-pigmentation resulting from the procedure, especially in individuals prone to hyper-pigmentation from scar or other injury.

Agree
Not Agree

I have been told that there may be risk and hazards related to the procedure planned for me.

Agree
Not Agree

I have been told that this procedure will involve pain and discomfort.

Agree
Not Agree

I understand that the pigments being used are not FDA approved and health consequences are unknown.

Agree
Not Agree

I have been told that the markings are permanent and there is a risk of pigment migration and infection following the procedure.

Agree
Not Agree

I have been told that a follow-up procedure may be required and that the color or the pigmentation may fade.

Agree
Not Agree

I have been told that there is a chance that I may experience a corneal abrasion from the eyeliner procedure.

Agree
Not Agree

I have been told that there is a chance of allergic reaction to pigment and that my body may reject the pigment.

Agree
Not Agree

I have been given the opportunity to ask questions about the procedure and the procedure to be used, the risks and the hazards involved, and I believe that I have sufficient information to give this informed consent.

Agree
Not Agree

I have agreed that if I shall have a complaint of any kind, whatsoever, I shall immediately notify Lisa Marie Bates. I further agree that any controversy or claim arising out of or relating to this consent and or any signed contract between myself and Lisa Marie Bates or the breach thereof, shall be settled by arbitration in the state of California in accordance with the Rules of the American Arbitration Association and judgment of the award rendered by the arbitrator(s) may be entered in any court having judgment thereof.

Agree
Not Agree

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Lisa Marie Bates.

Agree
Not Agree

I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its content.

Agree
Not Agree

Post Procedure Instructions are one of three (1 of 3) forms (including this one) you will be signing

I would Like to be notified of Lisa Marie's Cosmetic Solutions updates, promotions and specials.

Agree
Not Agree

I hereby authorize Lisa Marie Bates to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.

I certify that this form has been explained to me and I have read it. I understand its content.

Agree
Not Agree

Signature

3) Post Procedure Instruction

Tattoo Lightening/Removal Forms

Please fill out and sign the following 3 forms:

1) Medical History

Today's Date *

Name *

First

Last

Cell Phone *

Alternate Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Referred By

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Emergency Contact Relationship *

Please answer these questions truthfully to the best of your knowledge

The answers to these questions will helps us ensure the best possible outcome for your treatment from Lisa Marie's Cosmetic Solutions.

Are you now or have you been under the care of a Physician within the last two years? *

If yes, please describe why and provide Physician name, address and phone number

List all medications you are currently taking, including Retin A, Glycolic Acid, Acutane, and/or Latesse *

List all drug, make-up, skin or food allergies *

Have you currently undergone a skin peel, laser treatment or light treatment? *

If yes, which one and when?

What products do you use for your skin care regimen? *

Do you have or have you had any of the following conditions? *

Abnormal Heart Condition
High or Low Blood Pressure
History of cardiac valve disease
Herpes Simplex (any history, no matter how many years ago, specifically at procedure site)
Cold Sores
Fever Blisters
Hemophilia or other blood disorders
Prolonged Bleeding
Circulatory Problems
Diabetes
Cataracts
“Dry Eye”
Eye Surgery or Injury
Visual Disturbances
Tumors/Growths/Cysts
Epilepsy
Fainting spells/dizziness
Glaucoma
Corneal Abrasion
Blepharoplasty
Cancer
Chemotherapy/Radiation
Hepatitis
A Pacemaker or major heart problems
Collagen Vascular Disease
Auto-immune Disease (ex: Lupus/Rheumatoid Arthritis)
Are you currently pregnant?
History of allergic reactions to latex
History of allergic reaction to antibiotics
Do you use tobacco products?
Do you drink alcohol?
Do you require antibiotics prior to surgery or dental procedures?
Any risk factors for blood borne pathogens?
Are you using any eye drops or other ocular medications?
Have you ever experienced hyper-pigmentation from an injury?
Have you ever keyloided from a injury?
Are you currently taking aspirin or ibuprofen?

Date of your last eye exam? *

Eye Examining Physician’s Name *

Signature

2) Disclosure & Consent

Today's Date *//

Name *

First

Last

Date of Birth *//

Cell Phone *

Email *

I, as a client, have requested that Lisa Marie Bates describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. *

True
False

True
False

I voluntarily request as my Permanent Cosmetic Technician, Lisa Marie Bates and technical assistance as she may deem necessary to perform on my face and/or body the following procedure(s): *

I have informed Lisa Marie Bates that I am in good health and not under the care of any physician.

Yes I am not under the care of any physician
No I am currently under the care of a physician

If you answered NO, please list the condition(s) you are being treated for and your Physicians name, address and phone number.

I am 18 years or older.

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give my consent for this procedure.

Agree
Not Agree

I understand that no warranty or guarantees have been made to me as a result of my procedure.

Agree
Not Agree

I understand that there is a possibility of hyper-pigmentation resulting from the procedure, especially in individuals prone to hyper-pigmentation from scar or other injury.

Agree
Not Agree

I have been told that there may be risk and hazards related to the procedure planned for me.

Agree
Not Agree

I have been told that this procedure will involve pain and discomfort.

Agree
Not Agree

I understand that the pigments being used are not FDA approved and health consequences are unknown.

Agree
Not Agree

I have been told that the markings are permanent and there is a risk of pigment migration and infection following the procedure.

Agree
Not Agree

I have been told that a follow-up procedure may be required and that the color or the pigmentation may fade.

Agree
Not Agree

I have been told that there is a chance that I may experience a corneal abrasion from the eyeliner procedure.

Agree
Not Agree

I have been told that there is a chance of allergic reaction to pigment and that my body may reject the pigment.

Agree
Not Agree

Agree
Not Agree

Agree
Not Agree

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Lisa Marie Bates.

Agree
Not Agree

I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its content.

Agree
Not Agree

Post Procedure Instructions are one of three (1 of 3) forms (including this one) you will be signing

I would Like to be notified of Lisa Marie's Cosmetic Solutions updates, promotions and specials.

Agree
Not Agree

I certify that this form has been explained to me and I have read it. I understand its content.

Agree
Not Agree

Signature

3) Post Procedure Instruction

Microneedling Forms

Please fill out and sign the following 3 forms:

1) Medical History

Today's Date *

Name *

First

Last

Cell Phone *

Alternate Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Referred By

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Emergency Contact Relationship *

Please answer these questions truthfully to the best of your knowledge

The answers to these questions will helps us ensure the best possible outcome for your treatment from Lisa Marie's Cosmetic Solutions.

Are you now or have you been under the care of a Physician within the last two years? *

If yes, please describe why and provide Physician name, address and phone number

List all medications you are currently taking, including Retin A, Glycolic Acid, Acutane, and/or Latesse *

List all drug, make-up, skin or food allergies *

Have you currently undergone a skin peel, laser treatment or light treatment? *

If yes, which one and when?

What products do you use for your skin care regimen? *

Do you have or have you had any of the following conditions? *

Abnormal Heart Condition
High or Low Blood Pressure
History of cardiac valve disease
Herpes Simplex (any history, no matter how many years ago, specifically at procedure site)
Cold Sores
Fever Blisters
Hemophilia or other blood disorders
Prolonged Bleeding
Circulatory Problems
Diabetes
Cataracts
“Dry Eye”
Eye Surgery or Injury
Visual Disturbances
Tumors/Growths/Cysts
Epilepsy
Fainting spells/dizziness
Glaucoma
Corneal Abrasion
Blepharoplasty
Cancer
Chemotherapy/Radiation
Hepatitis
A Pacemaker or major heart problems
Collagen Vascular Disease
Auto-immune Disease (ex: Lupus/Rheumatoid Arthritis)
Are you currently pregnant?
History of allergic reactions to latex
History of allergic reaction to antibiotics
Do you use tobacco products?
Do you drink alcohol?
Do you require antibiotics prior to surgery or dental procedures?
Any risk factors for blood borne pathogens?
Are you using any eye drops or other ocular medications?
Have you ever experienced hyper-pigmentation from an injury?
Have you ever keyloided from a injury?
Are you currently taking aspirin or ibuprofen?

Date of your last eye exam? *

Eye Examining Physician’s Name *

Signature

2) Disclosure & Consent

Today's Date *//

Name *

First

Last

Date of Birth *//

Cell Phone *

Email *

I, as a client, have requested that Lisa Marie Bates describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure. *

True
False

True
False

I voluntarily request as my Permanent Cosmetic Technician, Lisa Marie Bates and technical assistance as she may deem necessary to perform on my face and/or body the following procedure(s): *

I have informed Lisa Marie Bates that I am in good health and not under the care of any physician.

Yes I am not under the care of any physician
No I am currently under the care of a physician

If you answered NO, please list the condition(s) you are being treated for and your Physicians name, address and phone number.

I am 18 years or older.

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give my consent for this procedure.

Agree
Not Agree

I understand that no warranty or guarantees have been made to me as a result of my procedure.

Agree
Not Agree

I understand that there is a possibility of hyper-pigmentation resulting from the procedure, especially in individuals prone to hyper-pigmentation from scar or other injury.

Agree
Not Agree

I have been told that there may be risk and hazards related to the procedure planned for me.

Agree
Not Agree

I have been told that this procedure will involve pain and discomfort.

Agree
Not Agree

I understand that the pigments being used are not FDA approved and health consequences are unknown.

Agree
Not Agree

I have been told that the markings are permanent and there is a risk of pigment migration and infection following the procedure.

Agree
Not Agree

I have been told that a follow-up procedure may be required and that the color or the pigmentation may fade.

Agree
Not Agree

I have been told that there is a chance that I may experience a corneal abrasion from the eyeliner procedure.

Agree
Not Agree

I have been told that there is a chance of allergic reaction to pigment and that my body may reject the pigment.

Agree
Not Agree

Agree
Not Agree

Agree
Not Agree

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Lisa Marie Bates.

Agree
Not Agree

I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its content.

Agree
Not Agree

Post Procedure Instructions are one of three (1 of 3) forms (including this one) you will be signing

I would Like to be notified of Lisa Marie's Cosmetic Solutions updates, promotions and specials.

Agree
Not Agree

I certify that this form has been explained to me and I have read it. I understand its content.

Agree
Not Agree

Signature

3) Post Procedure Instruction

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