Consent Form - Cosmetic Tattoo - Lash Lovers & Brow Babes

PERMANENT MAKEUP

Record Book

Client Information

Name

Date

Date of Birth

Age

Gender

Female Male NB

Address

Phone

How did you hear about us?

Would you like to be added to our email list for news and exclusive offers?

Yes No

Medical History

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

Autoimmune Disorder Aids/HIV Bleeding Disorder Cancer Cardiac Valve Disease Chemotherapy Depression/Mood disorder Diabetes Eczema Eye surgery/injury Glaucoma Hemophilia Hepatitis Herpes/Cold Sores History of MRSA Hypertronic Scarring/Keloids Kidney disease Liver disease Pregnant/breastfeeding Psoriasis/Dermatitis Radiation Skin condition

Other

Have you ever had an allergic reaction to latex?

Yes No

Have you ever had an allergic reaction to antibiotics?

Yes No

Have you taken any of the following in the last 2 days: Aspirin, Ibuprofen, Coumadin, Alcohol?

Yes No

if yes, please specify

Do you wear contact lenses?

Yes No

Do you often have eye irritation, itching or watery eyes?

Yes No

Client History

Have you had any permanent or semi-permanent makeup services done before?

Yes No

If yes, what kind of permanent makeup did you do?

Have you ever had any of the following surgeries?

Blepharoplasty (eyelid surgery)

Yes No

If yes, when?

Forehead / brow lift

Yes No

If yes, when?

Lasik eye surgery

Yes No

If yes, when?

Have you had any facial or dermatology services in the last 30 days?

Yes No

Have you recently done a chemical peel?

Yes No

If yes, when?

Are you currently wearing lash extensions?

Yes No

Do you have a tanned/sunburnt skin?

Yes No

Have you used Latisse or any eyelash/eyebrow growth conditioner within the last 2 months?

Yes No

Have you received Accutane (acne medication) within the last year?

Yes No

Have you received Botox, Lip fillers, Restylane, Juvederm or Collagen in the last 6 months?

Yes No

Have you used Retin-A, Renova, AHA, BHA, Retinoid or Retinol products in the last 3 months?

Yes No

By signing below, you agree to the following: I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition/s that would make the requested treatment unsuitable. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health.

Consent

Although every precaution will be taken to ensure your safety and wellbeing before, during and after your microblading, please be aware of the following information and possible risks.

Although every precaution will be taken to ensure your safety and wellbeing before, during and after your cosmetic tattoo, please be aware of the following information and possible risks.

I hereby consent to and authorise Kara from Alchemy Cosmetica to preform the following procedure:

Please tick each statement:

I am over the age of 18 and in sound mind, body, and health.

I understand that I will have permanent and/or semi-permanent cosmetic (referred to on this form as PMU/SPMU) makeup applied using the highest standards of hygiene and that sterile disposable needles and pigment containers are used for each individual client, procedure, and visit.

I understand and accept that permanent makeup is a process, often requiring multiple treatment visits to achieve desirable results and 100% success cannot be guaranteed.

I have been advised that the pigment result may vary according to skin tones, skin type, ethnicity, age, lifestyle, post-procedure care and general skin conditions. And I understand no guarantee on exact color results can be given.

I am aware that the true healed color will be visible 6-8 weeks after each procedure.

I accept the responsibility for determining and agreeing to the color, shape, and position of the PMU/SPMU procedure as agreed upon during the consultation.

I fully understand and accept that non-toxic pigments are used during the procedure and that the results will fade over time, however, some trace pigment may stay in the skin indefinitely.

I have been advised that annual touch-ups are encouraged to maintain the integrity of the color.

If an unforeseen condition arises in the course of the PMU/SPMU procedure, I authorize the technician to use his/her professional judgment in deciding what she feels is necessary under the given circumstances.

I can confirm that I have received before and aftercare instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.

If I wear contacts, I am aware that I must remove them prior to an eyeliner procedure.

I am aware that I must remove any false eyelashes prior to an Eyeliner/Lash Enhancement procedure. I am also aware that any lash enhancement serums or conditioners can affect the outcome of my Eyeliner/Lash Enhancement procedure.

I acknowledge that my skin is vulnerable to infection directly after a PMU/SPMU application, and I am to contact my primary physician if I see any signs of infection.

I understand that using cosmetics, excessive perspiration, and sun exposure should be limited until the skin has fully healed.

Allergic reactions are always a possibility. I understand that a patch test/allergy test does not guarantee that I will not have an allergic reaction and I release the technician from liability should I develop an allergic reaction to any of the topical preparations, pigments, dyes or the anesthesia used in the procedure.

I understand it’s impossible to list every potential risk and complication. I agree to have been informed of possible benefits, risks, and complications including but not limited to: redness or other discoloration, temporary bleeding, bruising, swelling, irritation, pain, fading or loss of pigment, and cold sores on lips.

I am aware that if I am to have an MRI after the procedure, I must tell the radiologist that I have iron oxide permanent cosmetics.

I understand that laser hair removal procedures may turn lip pigment dark or black.

I understand the positioning of my PMU/SPMU procedure can be affected if I elect to have cosmetic surgery, Botox, Restylane or other cosmetic or surgical procedures.

I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors that my technician has no control over. I understand that additional appointments after the initial and follow up appointments may be required.

I acknowledge that the procedure may result in a long lasting (many years) change to my appearance and that no representation has been made to me as to the ability to later change the results. I am aware that it can be costly to remove.

I understand tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.

I consent to the taking of before and after photos for the purpose of record keeping & documentation required by the Technician's insurance company.

I further authorize that exceptional photographs or results may be used in advertising or promotional materials and I give permission for such usage.

All medications and medical conditions have been disclosed to my technician as well as noted accurately and to the best of my knowledge on my intake/consultation form.

Being of sound mind and body, I hereby release and forever discharge the Technician at Alchemy Cosmetica from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my PMU/SPMU procedure. I fully accept any and all responsibility for any consequences that might stem from my decision to have a PMU/SPMU procedure performed by Kara Poll

Sign

PHOTO & VIDEO RELEASE FORM

I hereby grant and authorise Alchemy Cosmetica & Lash Lovers. I grant the right to capture, modify, edit, reproduce, exhibit, publish, distribute, and utilize any photographs, videos, and/or audio recordings taken of me for lawful promotional purposes. These materials may include, but are not limited to, newspapers, flyers, posters, brochures, advertisements, press kits, websites, social media platforms, and other forms of print and digital communication. I provide this authorization without expecting any payment or other forms of consideration. This authorisation remains in effect indefinitely and applies to all languages, media, formats, and markets, whether currently known or discovered in the future. I willingly waive any rights to royalties or other compensation arising from or related to the use of these photographs or recordings. I acknowledge and accept that the materials created through this agreement will be the property of Alchemy Cosmetica & Lash Lovers and will not be returned to me. I hereby release and discharge Alchemy Cosmetica & Lash Lovers from any liability, claims, or legal actions that may arise, including those made by myself, my heirs, representatives, executors, administrators, or any other individuals acting on my behalf or on behalf of my estate. By signing below, I confirm that I have thoroughly read and comprehended the entirety of the release agreement stated above.

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