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Koko King Semi Permanent Makeup Consent Form

 223 Dalhousie St, Ottawa, ON K1N 7E1

This form provides information about microblading/ Nano Brows which involves the application of semi-permanent makeup. You are encouraged to carefully review the information provided to make an informed decision as to whether to undergo the Semi Permanent Makeup procedure. This involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing. Initially the color will appear more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40-50%, soften, and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched up within 12-18 months. All instruments that enter the skin or encounter body fluids are disposable and disposed of after each use. Cross contamination guidelines are carefully adhered to. Generally, the results of Semi Permanent Makeup are excellent. However, a perfect result is not a realistic expectation, it is usual to expect a touch up after the healing is complete.

Possible risks, hazards, or complications:

PAIN: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.

INFECTION:Although rare, there is a risk of infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See "After Care" sheet for instructions on care.

UNEVEN PIGMENTATION: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance.

ASYMMETRY: Every effort will be made to avoid asymmetry but our faces are not symmetrical. Adjustments may be needed during the follow up session to correct unevenness. 

EXCESSIVE SWELLING OR BRUISING: Some people bruise and swell more than others. Ice packs may help, and the bruising and swelling typically disappear within 1-5 days. Some people don’t bruise or swell at all.

ANESTHESIA: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form   are typically used. If you are allergic to any of these please inform me now.

ALLERGIC REACTION: There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7-day patch test to determine this.

 

The alternative to these possibilities is to use cosmetics and not undergo this procedure. 

CONSENT FOR SEMI PERMANENT MAKEUP : 

Please read and initial if all following statements are true:

I am currently not under the influence of any drugs or alcohol.
I am NOT pregnant.
​I do not currently take nor have taken Accutane within the last 12 MONTHS.
I have not had Botox and/or other cosmetic filler procedures within the past two weeks.
I have not had any surgery of any kind in the past 6 months.
I have not taken any blood thinning medication within the past 72 hours nor have i taken Aspirin within the past 24 hours.
Aftercare instructions have been explained to me and are attached to this consent form. A written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If i have questions I will contact my technician.
I will contact my physician if I notice any infection beginning to form.
I understand a certain amount of discomfort is associated with this procedure and that swelling, redness, and bruising may occur.
I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color.
I understand that the sun, tanning beds, pools, some skin care products and medications may affect my permanent makeup.
I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done today.
I understand that implanted pigment may changer or fade over time due to circumstances beyond the salon's control and I will need to maintain the color with future applications and a touch-up session in 4-8 weeks.
I acknowledge that the Semi Permanent Makeup procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedure such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
I have been quoted the cost of today's appointment which includes (1) touch-up within 4-8 weeks following today's appointment. After 12 weeks, a fee will apply for any further touch-ups. There will be no refund for this elective procedure.
I acknowledge that I am at least 18 years of age and i certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Koreena King, to perform the Semi Permanent Makeup procedure on me. I hereby release Koreena King, and Smudge salon and its affiliates from any liability arising from the risks that are known and/or inherent in the Semi Permanent Makeup procedure.

- Must agree to move forward with treatment

I Agree

Signature:

August 20, 2019

Optional Photo Release Consent


Koko King would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc. Please circle "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.

YES, feel free to use photos of me

August 20, 2019 

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

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Appointment Time & Allergies

Please List All Allergies *

Clients Appointment Time *

Koko does offer Allergy scratch test 48hrs prior to service. If you have concerns about allergies and would like a scratch test preformed. You are to contact Koko via email at koreena.king@gmail.com Skin allergy testing or skin prick test is a method for medical diagnosis of allergies that attempts to provoke a small, controlled, allergic response. With semi-permanent brows there is a 3% risk of reaction. By not preforming a scratch test you are made aware and consent to this possible risk. Please let it be known that regular body ink is a different compound than semi-permanent ink, if you have had a tattoo in the past and feel "safe" please be advised that they are two different ink compounds. Meaning you could be reactive to one not the other. *
By Clicking YES you agree to participate in a Scratch Test*
No
Yes
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*
Applicable To Koko King Student Models

By clicking "YES" below, you are consenting to and fully aware that Koko King has  trained her student to the best of her ability and only allows students to work on models once fully capable of performing this semi permanent tattoo. She will be there through out the service guiding the student along and will help out if necessary. but as a Model for a student you are aware that you are consenting to have the student preform the brows to completion not Koko King. Moving forward with a touchup if will be preformed by the student at a different location or if you choose to have the touchup done by KoKo King it will require an additional fee off $200 to cover her supplies and time.

I consent to the information above regarding being a Student Model.*
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Appointment Time & Allergies

Please List All Allergies *

Clients Appointment Time *

Koko does offer Allergy scratch test 48hrs prior to service. If you have concerns about allergies and would like a scratch test preformed. You are to contact Koko via email at koreena.king@gmail.com Skin allergy testing or skin prick test is a method for medical diagnosis of allergies that attempts to provoke a small, controlled, allergic response. With semi-permanent brows there is a 3% risk of reaction. By not preforming a scratch test you are made aware and consent to this possible risk. Please let it be known that regular body ink is a different compound than semi-permanent ink, if you have had a tattoo in the past and feel "safe" please be advised that they are two different ink compounds. Meaning you could be reactive to one not the other. *
By Clicking YES you agree to participate in a Scratch Test*
No
Yes
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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