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Thank you for choosing Eyebrows Secret by Isabel Goulart. 

Isabel Goulart - License 028-MB-025

 

I am over the age of 18 and desire Isabel Goulart to perform the elective cosmetic eyebrows pigmentation procedure, understanding that this procedure is for aesthetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of the procedure calling for her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize her to do the necessary. I am aware that no guarantees have been made to me concerning the results of the procedure.


I also understand that the permanent skin pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes the risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and/or allergic reaction to any products used. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. Laser treatments may also compromise the permanent cosmetic make-up application. I fully understand as with all such procedures that this is not a science but an art and that anything that can go wrong. I request the permanent skin pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s). 


For documentation purposes, I also consent to the taking of before, during, and after photographs and/or videos of said procedure(s), which become the technician's sole property and may or not be used for whatever purposes deemed necessary. 


I certify that I have read and initiated the above paragraphs and have had it explained, and fully understand the above consent and procedure(s) permit; that the explanations therein referred to were made, and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request. 


Procedure: Eyebrows Microblading      No. of visits required: 2   

 

Cost of Procedure: $475.00 First Session $200.00 Touch Up 

 

IF YOU SMOKE, your results will be compromised to some degree. So stop smoking 

for a couple of weeks, prior to, and for a couple of weeks following the session. Or 

for as long as you can possibly hold out.

WHY? Because the carbon monoxide that has been lovingly added to your cigarettes 

has been proven to impede the healing process, by restricting the oxygen content in 

your blood... Less oxygen = slower healing time.

Will you heal if you continue to smoke? Yes. It will just take longer, which will allow 

more pigment to release, rather than heal in. Will you probably need more followup 

visits?  


I understand that this procedure is a process, and subsequent visits are necessary to achieve desired results.  


I will follow all "after-care" instructions thoroughly. Failing to do so will compromise my final results. 



Client refuses to disclose information listed  

Artist Signature 


 


First Client Name Name

First Name*

Last Name*

Phone*
First Client Name Date of Birth*
First Client Name Signature*
Second Client Name Name

First Name*

Last Name*

Phone*
Second Client Name Date of Birth*
Third Client Name Name

First Name*

Last Name*

Phone*
Third Client Name Date of Birth*
Fourth Client Name Name

First Name*

Last Name*

Phone*
Fourth Client Name Date of Birth*
Fifth Client Name Name

First Name*

Last Name*

Phone*
Fifth Client Name Date of Birth*
Sixth Client Name Name

First Name*

Last Name*

Phone*
Sixth Client Name Date of Birth*
Seventh Client Name Name

First Name*

Last Name*

Phone*
Seventh Client Name Date of Birth*
Eighth Client Name Name

First Name*

Last Name*

Phone*
Eighth Client Name Date of Birth*
Ninth Client Name Name

First Name*

Last Name*

Phone*
Ninth Client Name Date of Birth*
Tenth Client Name Name

First Name*

Last Name*

Phone*
Tenth Client Name Date of Birth*
Client Name 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*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Confidential Medical Profile
Have you had any alcohol or drugs in last 24 Hours?*
No
Yes
Do you have any allergies to latex?*
No
Yes
Are you anemic?*
No
Yes
To your knowledge are you allergic or resistant to over the counter level numbing products such as Lidocaine?*
No
Yes
The taking of medications such as aspirin or other anticoagulants (such as arfarin, Xarelto™, Plavix, Eliquis™, etc.) which thin the blood and or interfere with blood clotting;*
Yes
No
Do you hyper-pigment? (Tendency to develop dark spots on the skin from wounds or sun)?*
No
Yes
History of skin disease, skin lesions, or skin sensitivities to soap, disinfectants, etc*
No
Yes
Do you tend to develop keloid or hypertrophy scars?*
No
Yes
Bloodborne conditions such as Hepatitis B, Hepatitis C, HIV*
No
Yes
History of allergies or adverse reactions to pigments, dyes, or other skin sensitivities*
No
Yes
Do you have high or low blood pressure?*
No
Yes
History of diabetes or any disorder or medication that affects the neurological or immune system in fighting infection?*
Do you have autoimune disorders?*
No
Yes
Are you nursing? No anesthesia will be applied for nursing mothers without a doctor's note allowing us to use topical numbing.*
No
Yes
History of epilepsy, seizures, fainting, or narcolepsy*
Yes
No
To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions:
Do you have previous Permanent Make Up?*
No
Yes

If yes when?
Are you over the age of 18? Legal guardian's initials _______*
No
Yes
Have you had Botox or injectables?*
No
Yes

If yes when?
Do you take Antidepressants or mood altering medication?*
No
Yes
Have you had chemical or laser peel?*
No
Yes

If so when?
Do you have any problems with healing?*
No
Yes
History of skin disease, skin lesions, or skin sensitivities to soap, disinfectants, etc*
No
Yes
History of or suspicion of adverse reaction to latex or products containing latex?*
No
Yes
History of keloid formation? *
No
Yes
Have you eaten in the last 4 hours prior to the appointment?*
No
Yes
Are you currently under the influence of alcohol or drugs at the appointment time?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
No
Yes
History of hemophilia or any other blood clotting abnormalities?*
No
Yes
Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?*
No
Yes
Are you pregnant or nursing? Or have been pregnant within the last 3 months?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Hepatitis?*
No
Yes
Any tendency to bleed excessively from minor cuts?*
No
Yes
Do you have Epilepsy/ Seizures of any kind?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes

If yes, please explain.

Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all.

Client should consult a physician prior to procedure if they have any concerns related to conditions.

The health conditions listed may increase health risks associated with receiving a body art procedure.

I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), or scarring is a possibility as a result of my body's reaction to the skin being broken during the procedure. I realize that my body is unique and that Isabel Goulart cannot predict how my body will react as a result of this procedure.*
No
Yes
I acknowledge that it is not reasonably possible to determine whether I might have an allergic reaction to any of the pigments, dyes, topical preparations , or processes used in the procedure; and I agree to accept the risks that such a reaction although rare, is possible. I have informed Isabel Goulart of any existing problems.*
No
Yes
Alopecia clients- due to the change in skin texture, may require more frequent touch-ups, and in some cases, the pigment will not retain.*
No
Yes
I acknowledge and understand that pigment implanted on darker skin types( i.e. Indian, African American, Philipino and there like), will appear softer and blend more with your own skin melanin and will not appear as bold or crisp as on lighter skin types.*
No
Yes
Client refuses to disclose information listed.*
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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. Client is voluntarily obtaining services of their own free will and volition Client has had the opportunity to read and understand the documents presented Client has the ability to ask questions about the procedure Client has received and understands written and verbal aftercare Client should consult a physician prior to procedure if they have any concerns related to conditions. The health conditions listed may increase health risks associated with receiving a body art procedure. Consult a healthcare provider at first sign of infection - Cherokee County Health Dept (770) 928-0133


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