Loading...

Eyebrows, Lips & Eyeliner


Waiver, Release and Consent Form

Please read and initial all line

Aftercare instructions will be explained to me and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email Ieva Oliveira at browsbyieva@gmail.com, 416-804-6749.


 

I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur which will subside within 1-4 days. In some cases, bruising may occur. 


I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the colour and cause premature exfoliation of the pigment. 


I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup. 


I understand that successful colour saturation can NOT be guaranteed due to hidden scar tissue. 


I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary according to skin tones, skin type, age, and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact colour can be given. 


         

I accept the responsibility to explain to you my desire for specific colour , shape, and position for any procedure done today. 


I understand that implanted pigment colour can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the colour with future applications and a touch-up session within 4-8 weeks . 


I acknowledge that the proposed procedures(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as: infection, scarring, misplaced pigment, poor colour retention and hyper-pigmentation. 


I have been advised that a touch-up session is highly recommended to make any adjustments to shape, colour, and to fill any pigment that may have had poor retention. Touch-ups must be completed within 4-8 weeks of initial procedure to be considered a touch-up price. The cost is $125.00. 



I hereby consent to and authorize Ieva Oliveira (Permanent Beauty by Ieva) to use photographs and/or videos taken before, during, and after the specified permanent makeup procedure. I understand that these images may be used on the website, social media platforms, and in-office for promotional and demonstration purposes. I acknowledge that I am not entitled to any compensation for the use of these photos.


I certify that I have read, or have had read to me, the contents of this form. I understand the risks and alternatives involved in the procedures. I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material provided to me, and I authorize Ieva Oliveira, as my permanent makeup technician, to perform the desired semi-permanent or permanent makeup procedures on my eyebrows, eyeliner, and lips as outlined today.


 By signing below, I certify that my initials above indicate I have read and understand the above paragraphs. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.


I agree that all the above information is true and accurate to the best of my knowledge

​Dated: December 21, 2024 


Who will be having the procedure.....
AdultMinor
Continue
First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Information

Do you have or previously had any of the following:


How did you hear about me ?
Are you in general good health?*
No
Yes
Botox or Fillers*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Are you prone to Keloid formation?*
No
Yes
Mitral Valve Prolapse or Valve Implants (need antibiotics prior the treatment)*
No
Yes
High Blood Pressure*
No
Yes
Pregnant now - Breastfeeding now*
No
Yes
Thyroid Conditions*
No
Yes
Autoimmune disorder*
No
Yes

(Lupus, RA,AS, Crohns)
Oily Skin*
No
Yes
Rosacea*
No
Yes
Psorasis*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy / Radiation*
No
Yes
Accutane or acne treatment*
No
Yes

Last Treatment
Chemical Peel*
No
Yes

Last Treatment
Tan by booth or salon*
No
Yes
Glaucoma ( for Eyeliner only )*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Any diseases or disorders not listed*
No
Yes

If yes, please provide:
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?*
No
Yes
Allergies to metals, food, etc*
No
Yes

If yes, please provide
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol etc*
No
Yes

If yes, please provide
Allergies to Latex*
No
Yes
Cold Sores/Fever Blisters/Herpes ( for Lip liner or Lip Fill )if so are you taking Valtrex ?*
No
Yes

Please list any medications you are taking

I agree that all the above information is true and accurate to the best of my knowledge


First Clients Signature*
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Do you have or previously had any of the following:


How did you hear about me ?
Are you in general good health?*
No
Yes
Botox or Fillers*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Are you prone to Keloid formation?*
No
Yes
Mitral Valve Prolapse or Valve Implants (need antibiotics prior the treatment)*
No
Yes
High Blood Pressure*
No
Yes
Pregnant now - Breastfeeding now*
No
Yes
Thyroid Conditions*
No
Yes
Autoimmune disorder*
No
Yes

(Lupus, RA,AS, Crohns)
Oily Skin*
No
Yes
Rosacea*
No
Yes
Psorasis*
No
Yes
Cancer*
No
Yes

Year
Chemotherapy / Radiation*
No
Yes
Accutane or acne treatment*
No
Yes

Last Treatment
Chemical Peel*
No
Yes

Last Treatment
Tan by booth or salon*
No
Yes
Glaucoma ( for Eyeliner only )*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Any diseases or disorders not listed*
No
Yes

If yes, please provide:
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?*
No
Yes
Allergies to metals, food, etc*
No
Yes

If yes, please provide
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol etc*
No
Yes

If yes, please provide
Allergies to Latex*
No
Yes
Cold Sores/Fever Blisters/Herpes ( for Lip liner or Lip Fill )if so are you taking Valtrex ?*
No
Yes

Please list any medications you are taking

I agree that all the above information is true and accurate to the best of my knowledge


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. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!