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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 elible to recieve this treatment. 

Please do not hesitate to ask us any questions. 

Please tell us who is being treated today
AdultMinor
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First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
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.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Health History

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

Are you currently pregnant or nursing?*
No
Yes
Have you had any mood altering drugs or alcohol in the past 24 hours?*
No
Yes
Are you on any form of blood thinners? E.g., Aspirin, ibuprofen, acetaminophen, fish oils, vitamin A or E.*
No
Yes
Have you taken ANY blood thinners in the past 24 hours?*
No
Yes
Have you had any caffeine/coffee in the past 24 hours?*
No
Yes
Are you currently taking/prescribed opioids?*
No
Yes

Please list any medications you are currently taking
Are you currently undergoing chemotherapy or radiation treatments?*
No
Yes
History of MRSA?*
No
Yes
Botox in the past 3 weeks?*
No
Yes
Diabetes?*
No
Yes
Hepatitis (any)*
No
Yes
A pacemaker?*
No
Yes
Have you taken Accutane in the past year?*
No
Yes
Do you have any allergies to metal? Ie., iron, surgical steel*
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

Please list any other allergies.
Do you have any issues healing? Are you ever prescribed antibiotics prior to dental procedures?*
No
Yes
Have you previously had permanent makeup procedures?*
No
Yes
Do you have any history of skin diseases or remarkable skin irritations such as eczema or psoriasis?*
No
Yes
Describe your skin type. *
Dry
Normal
Oily
Combination (oily t-zone, dry everywhere else)
Are you currently tanned?*
No
Yes
Do you use any Glycolic Acid, Rentin A/Retinol, or Alpha Hydroxy Acid?*
No
Yes
Consent
I understand that a certain amount if discomfort is associated with this procedure and that swelling, redness and bruising may occur. The nature and method of the proposed Permanent Makeup (tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the 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 understand that Retin A, Retinols, Glycolic Acid, and Alpha Hydroxy Acid must not be used on treated areas. They will alter the colour and cause premature exfoliation of the pigment.*
No
Yes
I understand that tanning beds, some skin care products, and medications can affect my treatment and/or outcome.*
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 have been advised that this in not a one-step treatment and that a touch-up session is required to make any adjustments to shape, colour, and to fill in any pigment that may have had poor retention. Touch-ups must be completed within 90 days of the original procedure. Maintenance touch-ups are scheduled as needed and may vary from six months to three years. Fees for maintenance visits, pigment replacements, and scar camouflage are based on current published rates.*
No
Yes
I understand that implanted pigment can change slightly or fade over time due to circumstances beyond your control, and I will need to maintain the colour with future applications.*
No
Yes
I acknowledge that the proposed procedure(s) involve risks or complications such as: infection, misplaced pigment, poor colour retention.*
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 risk that such a reaction is possible. I have informed my practitioner of any existing problems.*
No
Yes
I understand the risks involved in this procedure(s).*
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 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 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 and that the professional recommendation is a NATURAL LOOK.*
No
Yes
I understand that in the event of a CAT scan or MRI, i must inform my physician that i have had permanent cosmetics. Some pulling or burning sensation may occur during the 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
Aftercare
Aftercare instructions have been 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 you.*
No
Yes
Patch Test
I have been offered a patch test to determine whether or not I will have adverse side effects to this procedure. If I choose to have a patch test, it will be completed prior to the procedure. I realize that there still remains a possibility of an allergic reaction to the applied pigments that may be delayed. *
I choose to have a patch test prior to this procedure.
I choose to WAIVE the patch test.
Model Release
For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by The Perfect Feather and/or anyone authorized by you, of any and all photographs in which you have this day taken of me negative or positive, for any purpose whatsoever, without further compensation to me. All images, together with prints, shall constitute your sole property, solely and completely. We will never tag you in any of our photos posted on social media.*
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.
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.


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