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Permanent Makeup

Please complete this medical questionnaire and consent form prior to your treatment.​ All of your information is kept private and secure and is used to help us determine that you are a candidate for this treatment. 

IF YOU HAVE COMPLETED THIS FORM WITHIN THE PAST 12 MONTHS, YOU DO NOT NEED TO DO IT AGAIN UNLESS SOMETHING HAS CHANGED. Please do not hesitate to ask us any questions. 

Please tell us who is being treated today
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First Clients Name

First Name*

Last Name*
First Clients Date of Birth*
First Clients Signature*
Parent or Guardian's Email Address

Email*

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

Please read the following carefully. Please ask any and all questions that you may have.

Have you previously had permanent makeup procedures? Check all that apply. *
Eyeliner
Microblading
Powder Brows
Lip Blush/Lip tattoo
None
If you have had previous permanent makeup and/or tattoo's did you have any issues healing?*
No
Yes
Are you currently pregnant or nursing?*
No
Yes
Have you had any mood altering drugs or alcohol in the past 24 hours?*
No
Yes
Have you taken ANY blood thinners in the past 7 days? E.g., Aspirin, ibuprofen, acetaminophen, fish oils, vitamin A or E.*
No
Yes
Have you had any caffeine/coffee in the past 24 hours?*
No
Yes
Do you have any of the following. Check all that apply. *
Dermatitis
Rosacea
Eczema
Psoriasis
Alopecia
None
Describe your skin type. *
Dry
Normal
Oily
Combination (oily t-zone, dry everywhere else)
Do you routinely use any Glycolic Acid, Rentin A/Retinol, Alpha Hydroxy Acid, Salycilic acids or any other form of anti-aging products?*
No
Yes
Are you currently tanned?*
No
Yes
Do you hypo-pigment? (lack of pigment)*
No
Yes
Do you hyper-pigment? (develop dark spots on your skin from sun or wounds)*
No
Yes
Do you scar easily from minor skin injuries (scrape, burn, etc.)*
No
Yes
Have you taken Accutane or any other prescribed topical acne medication the past year?*
No
Yes
Have you ever had cold sores or fever blisters?*
No
Yes
Have you had botox or fillers in the past 3 weeks?*
No
Yes
Are you currently undergoing chemotherapy or radiation treatments?*
No
Yes
Have you ever had MRSA (antibiotic resistant skin infection)?*
No
Yes
Are you diabetic?*
No
Yes
Do you have a history of stroke or heart attack?*
No
Yes
Do you have any allergies to topical antibiotics, preparations, or desensitizers? E.g., polysporin, bacitracin, neosporin, petroleum, or any "caine" products such as lidocaine.*
No
Yes
Do you have any issues being 'numbed' or 'frozen'? E.g., at the dentist you require more numbing than a typical patient?*
No
Yes
Do you bleed or bruise easily?*
No
Yes
Are you using any eyelash or eyebrow growth serums such as Latisse or Eyenvy?*
No
Yes
Do you have glaucoma or any other eye diseases?*
No
Yes
Have you had any eye surgeries?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have any autoimmune disorders?*
No
Yes

Please list ALL medications you are currently taking

Please list any allergies.
Medical Conditions/Medications of Concern
I agree to notify The Perfect Feather 72 hours prior to my appointment if I have any of the following health conditions or am on any of the listed medications. Email: info@theperfectfeather.ca Text: 778-881-4015*
No
Yes

Pregnant or nursing
At risk and sensitive due to changing hormones. 

Hemophilia
High Risk, cannot stop bleeding.

Heart Conditions/Pacemaker/Defibrillator 
High risk and on blood thinning medication. No exceptions. 

Body Runs Hot
Increased bleeding which prevents pigment deposit. 

Bleeding Disorders
Increased bleeding which prevents pigment deposit.

Thyroid condition and taking medications for this condition
Hypo or hyperthyroidism, graves disease, hashimotos, etc. result in thicker skin. More treatments may be required to achieve desired results. 

Autoimmune Disorders such as Lupus or Frontal Fibrosing Alopecia (MS, RA, Lupus or the like)
Due to the medications to treat these diseases the skin is altered and pigment will not retain. Also, the facial skin is typically not healthy and/or is bumpy. Pigment will not heal evenly. 

Trichotillomania (compulsive pulling of face/body hair)
Due to constant pulling scar tissue is prominent and pigment will not heal evenly/properly. 

Use of Glaucoma Eye Drops (eyeliner clients only)
Eyelash follicles and eyelids are hypersensitive and will bleed easily and pigment will not retain.

If you are on any of the following medications you may have excessive bleeding and pigment MAY NOT retain:

  • Accutane
  • Latisse /EyEnvy
  • Xalatan (Latanoprost)
  • Ticagrelor (Brilinta)
  • Dipyridamole (Persantine)
  • Glaucoma Eyedrops
  • Eliquis (Apixaban)
  • Retin-A
  • Coumadin
  • Ticopidine (Ticlid)
  • Travatan Z (Travapost)
  • Xarelto (Rivaraxaban)
  • Savaysa (Edoxaban)
  • Prasugrel (Effient)
  • Zioptan
  • Clopidogrel (Plavix)
  • Cilostazol 9Pletal)
  • Trifusal (Disgren)
  • Lumigan (Bimatoprost)
  • Paradaxia (Dibigatran)
  • Vorapraxar (Zontivity)

Consent
I certify that I am over the age of 19.*
No
Yes
I understand that permanent makeup is a TATTOO. As such a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.*
No
Yes
I acknowledge that the proposed procedure(s) involve risks or complications such as: skin irritations, misplaced pigment, poor colour retention.*
No
Yes
I realize that my body is unique and the practitioner cannot predict how my skin may react as a result of the procedure.*
No
Yes
I understand that due to the fact that the skin is opened during the treatment there is a possibility of complications during and following its performance. Secondary infection in the area of the procedure may occur; however, if properly cared for, occurrence is rare.*
No
Yes
I consent to the use of such topical anesthesia considered necessary or advisable.*
No
Yes
I understand that tanning beds (UV exposure), medications and some skin care products (Retin A, Retinols, Glycolic Acid, Alpha Hydroxy Acid etc.) may affect my treatment and/or outcome. Over time, they will alter the colour and cause premature exfoliation of the pigment.*
No
Yes
I accept the responsibility to explain to you my desire for specific colours, shape, and position for any procedure done today.*
No
Yes
I understand that individual results will vary due to a variety of factors including my overall health, the health of my skin, and how well I follow the aftercare.*
No
Yes
I understand that Permanent Makeup is NOT a one-step treatment and that touch-up session(s) will be required to make necessary adjustments to shape, colour, and to fill in any spots that may have had poor retention. Touch-ups should be scheduled within 12 weeks of your first appointment. Maintenance touch-ups are scheduled as needed and may vary from six months to three years. Fees for maintenance visits are based on current published rates.*
No
Yes
I acknowledge that the procedure will result in a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the result.*
No
Yes
I understand that the colour will fade and diffuse over time due to environmental and lifestyle factors.*
No
Yes
I understand that future laser treatments or other skin-altering procedures, such as plastic surgery, implants, and/or injections may alter or degrade my Permanent Makeup. I further understand that such changes are not the fault of the practitioner. I further understand that such changes in my appearance may not be correctable through further Permanent Makeup procedures.*
No
Yes
I acknowledge that the obtaining of Permanent Makeup procedure(s) is my choice alone, and I consent to the application of the procedure and to its attendant risks, and to any actions or conduct of the practitioner and/or any of the practitioners associates reasonably necessary to perform the procedure(s).*
No
Yes
I acknowledge that no guarantees have been made to me concerning the results of this procedure.*
No
Yes
I certify that I have read, or have had read to me the contents of this form.*
No
Yes
I have had the opportunity to ask questions, and all of my questions have been answered.*
No
Yes
I authorize Erin Houldsworth, as my technician, to provide the procedure as desired today.*
No
Yes
Patch Test
I choose to have a patch test prior to this procedure.
I choose to WAIVE a patch test.
I understand that if I choose to HAVE a patch test that The Perfect Feather cannot determine the results (you either have to determine the results yourself or visit your family doctor for assistance).*
No
Yes
I understand that if I choose to WAIVE the patch test that The Perfect Feather is not liable for any allergic reactions or negative/adverse side effects.*
No
Yes
I acknowledge that even WITH a patch test 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 risk that such a reaction is possible. I have informed my practitioner of any existing medications, skin conditions, and medications.*
No
Yes
Appointment Preparation
I acknowledge that upon booking this appointment I was sent detailed instructions to help me prepare for my appointment and that I have followed them to the best of my ability.*
No
Yes
I acknowledge that if I fail to arrive fully prepared for my appointment and the technician is unable to proceed with the treatment as planned, I will forfeit my deposit. A new deposit will be required to book future treatments.*
No
Yes
Aftercare

Aftercare is just as important - if not MORE important that the treatment itself. You must be 100% committed to following the provided instructions. 

All of the aftercare instructions are available online at www.theperfectfeather.ca. Every client is emailed the instructions one week prior to your appointment. 

Detailed aftercare instructions will be provided after your appointment along with cleanser, ointment, and damp cotton rounds. Please save the tubes of ointment and cleaners for your touch-ups!

I acknowledge that it is my responsibility to follow aftercare instructions. Failure to follow instructions may result in poor retention, infection, or undesired healed results.*
Yes
I understand that due to the nature of permanent makeup, there are no guarantees on the outcome.*
Yes
Photo Consent
For the purpose of documentation, I consent to the taking of before and after photos. These photos will be stored with your confidential client records.*
No
Yes
I consent to the use of my photos for the purposes of marketing. My photos may appear in print or online (website, facebook, instagram). Your personal information (name) is never shared. Most photos are zoomed in/close up to show detailed work. Full face photos are rarely, if ever shared.*
No
Yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 19 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*
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.


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