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Thank you for choosing Eyebrows Secret by Isabel Goulart. 

 

I am over the age of 18 and desire Isabel Goulart to perform the elective cosmetic 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: Pixel Brows | Powder Brows            No. of visits required: 2   

Cost of Procedure: $475.00 First Session $150.00 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. 


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
Do you have any allergies to latex?*
No
Yes
Do you have any type of herpes?*
No
Yes
Are you anemic?*
No
Yes
To your knowledge are yo allergic or resistant to over the counter level numbing products such as lidocaine?*
No
Yes
Do you hyper-pigment? (Tendency to develop dark spots on the skin from wounds or sun)?*
No
Yes
Do you hypo-pigment? (Lack of pigment on the skin)?*
No
Yes
Do you have any type of hepatitis?*
No
Yes
Are you allergic to hair dyes?*
No
Yes
Do you have high or low blood pressure?*
No
Yes
Are you diabetic? If so,Type 1 or Type 2?*
Do you have autoimune disorders?*
No
Yes
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?
Have you had chemical or laser peel?*
No
Yes

If so when?
Do you have any problems with healing?*
No
Yes
Do you get fever blisters or cold sores?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently using Retin-A or Alpha Hydroxyl skin care products?*
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
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have Alopecia?*
No
Yes
Are you currently on Accutane Treatment?*
No
Yes
Do you have Keloid or Hypertrophy Scars?*
No
Yes
Do you have Hepatitis?*
No
Yes
Do you have any Autoimmune Disorders?*
No
Yes
Do you currently or have you had Cancer?*
No
Yes

If yes, please explain.

Do you have HIV?*
No
Yes

Please list any other medical conditions, and list all.
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
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 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
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
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.


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