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Our patient consultation waiver allows us to assess your health and assure you are protected from any underlying health issues you may have. Please read each question in its entirety before answering. 


INFORMED CONSENT TO PROCEDURE FOR PATIENTS

1.   I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed. 


2.   Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color.  


3.  I understand that the color selection and color results in all procedures are not an exact science. 


4. I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restalyne and I assume this responsibility. 


5.   I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics.  


6. If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.  


7. I understand that this procedure will fade and this fading can alter the original pigment color and that this determines that it is time for a touch-up visit.  


8. I realize this is an elective cosmetic procedure and is not medically necessary. 


9. It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment. 


10. I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my Technician or anyone operating such that I have permanent make up. 


11. I give my consent to confer with my physicians for medical information required for the safety of my procedures.   


12. I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner. 


13. I am aware that if an infection occurs after I have received Permanent Cosmetics to see with my primary physician or an emergency room, immediately.  


14. If I had permanent cosmetics performed previously by another practitioner, I do not hold responsible for future allergic reactions or contraindications.  


15. If I am having microblading procedure performed, I understand I must stop using all anti-aging products and products that contain Retins, acids (Hyaluronic, Glycolic, etc.) 6 weeks prior to the procedure.  


16. If I am having permanent makeup (powder brows, ombre brows, etc.) procedure performed, I understand I must stop using all anti-aging products and products that contain Retins, acids (Hyaluronic, Glycolic, etc.) 10 days prior to the procedure. 


ACCEPTANCE:

I have read and understand these risks listed above and they have been explained to me.  I DID NOT JUST SIGN THIS DOCUMENT. I certify that the information in the above questionnaire is accurate, and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request.              



Please select who will be participating...
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First Patient Name

First Name*

Last Name*

Phone*
First Patient Date of Birth*
First Patient Information

Ethnic Background, please include all nationalities

Occupation:
If we call you at home, do you want confidentiality?*
No
Yes
May we call you at work?*
No
Yes

If Yes, my work number is

Who may we thank for referring you?
Procedure(s) desired:
Brows
Eyeliner
Lips
Correction

List all medications you are presently taking


Name of drug

Mg. or mcg.

How many ea. day

Why was it prescribed to you

List all medications you took in the last six months that you are no longer taking:


Name of drug

Mg. or mcg.

How many ea. day

Why was it prescribed to you
Do you have? (check all that apply)
Fever Blisters/Cold Sores (Ever, even one time)
Glaucoma or other eye disease/disorder
Grave's Disease
Heart Disease
Mitral Valve Prolapse
Valve Implants
Pacemaker
Stents
Diabetes requiring insulin
Problems with healing
Keloids
Seizures
Dermatological Disorder - ie. Shingles, Rosacea, Eczema, Psoriasis
Hemophilia or Clotting Disorder
Autoimmune Disorder
Pre-existing nerve damage
Tattoos
Trichotillomania (pulling of hair, brows, lashes)
Alopecia Totalis or Areata
Allergies
Allergic to epinephrine
Oily Skin
Rheumatoid Arthritis
Psoriasis

If Dermatological Disorder, what?

If Dermatological Disorder, Active or in Flare-ups?

If Tattoos, colors you are sun sensitive to:
Do you use? (check all that apply)
Accutane (currently or within the past year)
Antibiotics prior to dental procedures
Steroids
Retin-A, Glycolic Acid, Vitamin C or E or other Exfoliants
Tanning Beds
Eyebrow Tinting
Eyelash Tinting
Eyelash Growth Serum
Botox or Fillers
Chemical Peels
Chemotherapy or Prophylactic dose of Chemotherapy
Blood Thinners

If Botox or Fillers, when?

If Chemical Peels, when?
Are you? (check all that apply)
Pregnant
Planning cosmetic surgery
Currently under the care of a physician

If Planning cosmetic surgery, what & when?

If under the care of a physician, Describe
Have you had? (check all that apply)
Fever Blisters/Cold Sores (Ever, even one time)
Eye Infections (Are you prone to them)
Vision Correction Procedure (Lasik, RK) within the past 3 months
Heart Attack
Joint Replacement, Organ Transplant
Eye Trauma
Seizures
Fainting Spells
Hepatitis
Hepatitis Test
Fat Transfer Injection
Gore-Tex Implants - Nose enhancement
Aesthetic or Cosmetic Procedures
Laser Treatments

Click to customize text


If Heart Attack, when?

If Hepatitis - What Type:

If Hepatitis Test - When?

If Fat Transfer Injection, where?

If Gore-Tex Implants, where?

If Aesthetic or Cosmetic Procedures, where?

If Laser Treatments, what type & why?
Do you practice outdoor activities? Check all that apply
Tennis
Golf
Gardening
Boating
Swimming
Skiing
Walking
Other

Physician's Name:

Physician's Address:

Physician's Phone:

Physician's Specialty:
First Patient Signature*
Patient 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*
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

Ethnic Background, please include all nationalities

Occupation:
If we call you at home, do you want confidentiality?*
No
Yes
May we call you at work?*
No
Yes

If Yes, my work number is

Who may we thank for referring you?
Procedure(s) desired:
Brows
Eyeliner
Lips
Correction

List all medications you are presently taking


Name of drug

Mg. or mcg.

How many ea. day

Why was it prescribed to you

List all medications you took in the last six months that you are no longer taking:


Name of drug

Mg. or mcg.

How many ea. day

Why was it prescribed to you
Do you have? (check all that apply)
Fever Blisters/Cold Sores (Ever, even one time)
Glaucoma or other eye disease/disorder
Grave's Disease
Heart Disease
Mitral Valve Prolapse
Valve Implants
Pacemaker
Stents
Diabetes requiring insulin
Problems with healing
Keloids
Seizures
Dermatological Disorder - ie. Shingles, Rosacea, Eczema, Psoriasis
Hemophilia or Clotting Disorder
Autoimmune Disorder
Pre-existing nerve damage
Tattoos
Trichotillomania (pulling of hair, brows, lashes)
Alopecia Totalis or Areata
Allergies
Allergic to epinephrine
Oily Skin
Rheumatoid Arthritis
Psoriasis

If Dermatological Disorder, what?

If Dermatological Disorder, Active or in Flare-ups?

If Tattoos, colors you are sun sensitive to:
Do you use? (check all that apply)
Accutane (currently or within the past year)
Antibiotics prior to dental procedures
Steroids
Retin-A, Glycolic Acid, Vitamin C or E or other Exfoliants
Tanning Beds
Eyebrow Tinting
Eyelash Tinting
Eyelash Growth Serum
Botox or Fillers
Chemical Peels
Chemotherapy or Prophylactic dose of Chemotherapy
Blood Thinners

If Botox or Fillers, when?

If Chemical Peels, when?
Are you? (check all that apply)
Pregnant
Planning cosmetic surgery
Currently under the care of a physician

If Planning cosmetic surgery, what & when?

If under the care of a physician, Describe
Have you had? (check all that apply)
Fever Blisters/Cold Sores (Ever, even one time)
Eye Infections (Are you prone to them)
Vision Correction Procedure (Lasik, RK) within the past 3 months
Heart Attack
Joint Replacement, Organ Transplant
Eye Trauma
Seizures
Fainting Spells
Hepatitis
Hepatitis Test
Fat Transfer Injection
Gore-Tex Implants - Nose enhancement
Aesthetic or Cosmetic Procedures
Laser Treatments

Click to customize text


If Heart Attack, when?

If Hepatitis - What Type:

If Hepatitis Test - When?

If Fat Transfer Injection, where?

If Gore-Tex Implants, where?

If Aesthetic or Cosmetic Procedures, where?

If Laser Treatments, what type & why?
Do you practice outdoor activities? Check all that apply
Tennis
Golf
Gardening
Boating
Swimming
Skiing
Walking
Other

Physician's Name:

Physician's Address:

Physician's Phone:

Physician's Specialty:
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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