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GK Micro Artistry 2021

Photograph and Publicity Release Form

I, "Client" give my permission to use my image, appearance as such may be embodied in any pictures, photos, video recordings, digital images, and testimonials, re- views taken or made on behalf of G.k Micro Artistry. I agree that G.k Micro Artistry has com- plete ownership of such pictures , etc., including the entire copy right and may use them for illus- tration, bulletins, exhibitions, video types, reprint, reproductions, publication, advertisement, and any promotion or educational in any medium now known or later developed, including the inter- net . I acknowledge that I will not receive any compensation for the use of such pictures. I hereby release G.k Micro Artistry from any and all claims which arise out of the use of any images used as stated above.

I have read and understood this consent and release.

I give my consent to G.k Micro Artistry to use my likeness to promote their company and or their activities

I Agree

CONSENT TO APPLICATION OF

PERMANENT COSMETIC PROCEDURE

Please initial each area highlighted after you have read these statements and agree with their content.

I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure(s). The general nature of cosmetic tattoo- ing as well as the specific procedure to be performed has been explained to me.

I Agree

PROCEDURE(s):

EXPECTED NO. OF VISITS REQUIRED: COST OF PROCEDURE(s):

I have been informed of the nature, risks, and possible complications and consequences of permanent cosmetics (permanent skin pigmentation/cosmetic tattoo). I understand the permanent cosmetic procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent cosmetic procedure(s), and accept the perma- nence of the procedure, acknowledge the likelihood of fading over time, as well as the possible complica- tions and consequences of the said procedure(s).

I Agree
 I understand that if I have any skin treatments, laser hair removal, plastic surgery, or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.
I Agree
I have received pre- and post-procedure 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. I have disclosed all medications and/or drugs I am taking either prescription or non- prescription and their purpose or indications. I have disclosed any medical conditions that may affect the healing of my skin pigmentation
I Agree
I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s).
I Agree
I understand that I will not hold G.K MICROARTISTRY accountable for any fading or retention of ink and that sometimes it could require multi- ple touch ups due to lifestyle or specific skin types or medication that can cause the skin not to heal correctly. I understand there is a No Refund Policy and any touch ups necessary will be a separate cost of price quoted. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this permanent cosmetic procedure(s) performed.

 

PERMANENT COSMETICS

PRE-PROCEDURE INFORMATION

All permanent cosmetic procedures are multi-session processes. You are required to come back for at least one touch-up visit before it can be determined that your work is complete. Touch-up visits are scheduled at 4-6 week intervals. Extra touch ups may be necessary to achieve desired result and is a separate cost.

I Agree

Be prepared for the color intensity of your procedure to be significantly sharper, brighter, or dark- er than what is expected for the final outcome. It will take time for this transition and is based up- on how quickly the outer layer of your skin exfoliates.

While these tattooed colors may initially simulate the exact color and tone desired, they will not always remain a perfect match. Tattooed colors are constant, while your own skin color will vary depending on exposure to cold, heat, sun and circulatory changes. For example, if you tan your skin and had a scar cam- ouflaged, your surrounding skin will be darker in appearance than the treated area.

  1. Since delicate skin or sensitive areas may swell slightly or redden, some clients feel it best not to make any social plans for a day or two following any procedure. It is always best to avoid these procedures within months prior to important life events such as weddings. Procedures may take longer than expected to be completed under some circumstances.
  2. Wear your normal makeup and bring your lip color or brow pencils to the office on the day of the procedure.
  3. Any tweezing or waxing should be done at least 48 hours prior to the procedure; electrolysis no less than five days before. Do not resume any method of hair removal for at least two weeks.
  4. Any eyelash or eyebrow tinting or eyelash curling should be done no sooner than 48 hours before, or two weeks after the procedure.
  5. Refrain from the use of alcohol, aspirin, aspirin-containing medications, ibuprofen, or other blood- thinning medications for seven days before and two days after any procedure. Refrain from judg- ment-altering drugs for at least 24 hours prior to any procedure. No medication should ever be discontinued without first consulting your physician.
  6. A skin test is offered upon request.

Practitioner makes no attempt to, or claim to, practice medicine. Some Individuals will have complications related to permanent make up application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible reason restriction you from receiving a tattoo, you must approve of the design and color before the application of your permanent makeup.

I "client" Approve of Mapped Shape & Color before starting and authorize and give full consent Gk Microartistry to perform permanent cosmetics. I do not hold Gk Microartistry accountable and agree to a No refund policy.

 

Post- Procedure

EYEBROW

  • Expect slight swelling, thickness, and redness for 1-2 days following the pro-
  • cedure.
  • Keep the treated area lightly glossed with A&D 1-2 times a day for 7-10 days of
  • healing time. Wash with cold water and pat dry.
  • Use a very thin amount of petroleum for aftercare and blot off excess with a
  • clean tissue for 7 days.
  • Keep area clean, but do not wash with soap for 3 days. By the 4th day you may
  • clean the area using a very gentle soap (Dove) DO NOT RUB area vigorously
  • when washing your face for at least 10 days.
  • Do not try to remove the excess color with soap. This color will flake and fade
  • to a beautiful, natural color if left undisturbed.
  •  

Keep area away from water for 24 hours. Keep moist with A&D

Remember:

  • DO NOT use any Retin - A or Glycolic Acid while healing DO NOT use Peroxide or Neosporin on any areas.
  • DO NOT scrub or pick at the treated areas
  • DO NOT expose area to sun or tanning beds
  • DO NOT do any facials, swimming, spa for at least 5 days.
  • DO NOT dye or tweeze eyebrows for one week before and after procedure No Exercise or sweating for 24 hours

Seek Medical help or see a physician if you experience symptoms such as excessive swelling, redness, yellow or green discharge, fever, or see streaks running towards the heart- which could indicate sign of an infection.

 

CONSENT TO APPLICATION OF PERMANENT COSMETIC PROCEDURE

I understand that the FDA has not approved of any: inks, dyes, or pigments and that health effects are unknown.

 Client CHART NOTES:

Needle size: .30mm,.25mm,1RL,.30/.25mm 3RL).25 3RS

lot # 012021,082022,052022

procedure: OMBRE POWDER 

Supreme permanent

.25RL, .25 RLMT,.30RLMT

LOT #220101

Lot#211001

1201RL LOT:2023-06-01

1001RL 2023-06-01

1003RL 2023-10-01

0801RL 2022-11-01 


.30 8u Pixl cartridge 022023

.25 3RL 022023


 

 




First Client’s Name

First Name*

Last Name*

Phone*
First Client’s Date of Birth*
First Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
First Client’s Signature*
Second Client’s Name

First Name*

Last Name*
Second Client’s Date of Birth*
Second Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Third Client’s Name

First Name*

Last Name*
Third Client’s Date of Birth*
Third Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Fourth Client’s Name

First Name*

Last Name*
Fourth Client’s Date of Birth*
Fourth Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Fifth Client’s Name

First Name*

Last Name*
Fifth Client’s Date of Birth*
Fifth Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Sixth Client’s Name

First Name*

Last Name*
Sixth Client’s Date of Birth*
Sixth Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Seventh Client’s Name

First Name*

Last Name*
Seventh Client’s Date of Birth*
Seventh Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Eighth Client’s Name

First Name*

Last Name*
Eighth Client’s Date of Birth*
Eighth Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Ninth Client’s Name

First Name*

Last Name*
Ninth Client’s Date of Birth*
Ninth Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Tenth Client’s Name

First Name*

Last Name*
Tenth Client’s Date of Birth*
Tenth Client’s Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
COVID-19
Have you traveled outside the U.S within the last 3 months?*
no
yes
Do you have a fever or felt feverish recently?*
no
yes
Do you have flu like symptoms?*
no
yes
Have you been been diagnosed or been in contact with Covid-19 in the past 3 weeks?*
no
yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Are you over the age of 18?*
Yes
No
Have you had any aspirin or blood thinning products within the last 7 days?*
Yes
No
Do you have any problems with healing?*
Yes
No

If so, when?:
Have you had any pervious problems with tattoo , or as has your physician advised you not to have a tattoo at this time?*
Yes
No
Are you currently undergoing radiation or chemotherapy?*
Yes
No
Have you ever had any permanent make-up procedures done in the past?*
Yes
No
Are you taking any anti-inflammatory medications or steroids?*
Yes
No
Are you allergic to any topical antibiotic preparations or desensitizers? (I.E. polysporin, bacitracin, Neosporin or "Caine" family of drugs or petroleum)*
Yes
No
Are you pregnant or nursing?*
Yes
No

Please Circle any of the following that may pertain you : 

Heart Condition
Allergies to make up
Acutance treatment
Dry eye
Shortness of breath
Keloid or hypertrophy scars
Keloid formation
Refractive eye surgery
Alopecia
Diabetes
Autoimmune Disorders
Trichotillmania
Hepatitis / Jaundice HIV
Kidney disease
Tendency to develop fever
Excessive bleeding from minor injuries
Chest pain
Glaucoma
Epilepsy/ seizures
Stroke
Ocular herpes - Cancer any type
Please select "yes" Only if you have Hemophilia: a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper..


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