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Today's Date: <br />N <br />Permanent Cosmetics Information Sheet <br />aLiu Consent Forms <br />Driver's License #: <br />Date of Birth: [F] [M] <br />Address: Apt#: <br />City: State: Zip: <br />Home Phone: ( ) Cell: <br />Your e-mail address: <br />If we call you at home, do you want confidentiality? No Yes <br />May we call you at work? No Yes If yes, my work number is: ( ) <br />Emergency Contact: Phoned ) Relationship: <br />Ethnic Background, please include all nationalities: (this information will help us choose the <br />correct pigment color for your skin type) <br />Who may we thank for referring you? <br />Procedure(s) Desired: Brows R <br />Eyeliner � Lips � Camouflage <br />El <br />Areola Complex F1 Correction <br />Clinical Outcome of Procedure(s): <br />1. The result of your procedure is determined in part by the nature of the pathology <br />of skin type, but not limited to the following factors: <br />■ Medication you are currently taking. <br />■ Skin characteristics: Dryness, oiliness, thickness, sun -damaged, color, <br />chemically damaged, etc. <br />■ Natural skin undertones mixing with pigment color. <br />■ Personal pH balance of skin, tanning booths, fruit acids, AHA's and Retin <br />A use. <br />■ Alcohol intake, smoking, sun exposure and improper skin care. <br />■ Following Pre and Post instructions. <br />■ In some cases, these factors can or may interfere with acceptance and <br />overall fading of color pigment. <br />1 <br />