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Microblading | Nano Brow Informed Consent.

All information is collected by Ivonne Sanchez Beauty pursuant to O. Reg. 136/18: PERSONAL SERVICE SETTINGS and The Personal Information Protection and Electronic Documents Act (“PIPEDA “).

Terminology

The words “I”, “you” and “your" are used interchangeably throughout this agreement and in all cases refer to you the client who is receiving the treatment or procedure.

“Microblading“ and "Nano Brow" is a form of semi to permanent makeup tattoo that involves tattooing ink into the skin to provide fullness and shape to eyebrows. As a general approximation, the effects of Microblading may last up to 8-12 months, and Nano Brows may last up to 18 months, depending on such factors as skin type and lifestyle.

“Practitioner”, “technician”, “instructor” and “we” means 10981508 CANADA INC. (“Ivonne Sanchez Beauty”), its staff or contractors.
 

SECTION 1: ACKNOWLEDGMENTS AND AGREEMENTS

Please read each statement and sign the end of this document to accept your acknowledgement and agreement to the following:

That I have been given a copy of this Consent and Liability Release (the "Release") prior to the MICROBLADING or NANO-BROW technique being performed on me.

That it is my responsibility to advise the technician of any concerns I may have before participating as a client/customer and having this service performed on me, even though I may have written it down in this Release.

That I have read and accepted the risks set forth in Section 2. I have been given the opportunity to ask questions, either by written or verbal communication, prior to signing this Release. As a result, I have sufficient information to give this informed consent.

That I must complete the Health Questionnaire in Section 3 before I can have this service performed on me. I understand my participation as a client may be refused depending on my responses, including but not limited to, if I am pregnant, nursing or if I have any allergies or contraindications.

That no warranty or guarantee has been made to me as a result of the Eyebrow MICROBLADING or NANO BROW technique, and that the final result cannot be guaranteed as each skin type is unique.

SECTION 2: RISKS

I acknowledge and accept the following risks:

1. During the treatment, despite all precautionary measures, injury is possible. I will not hold the technician or business performing this service on me responsible in any way for any damages or issues that may arise as a result of having the MICROBLADING or NANO BROW procedure performed on me.

2. Despite application of the most advanced and top ingredients, an allergic reaction is possible.

3. Despite all measures taken, the risk of with EYEBROW MICROBLADING or NANO BROW is that some of the products or tools could make contact with the eyes, or eye area, resulting in temporary or permanent pain or chronic eye conditions, up to temporary or permanent vision loss.  Although a low risk of infection it is possible to contract pink eye (conjunctivitis), or bacteria related infections from Staphylococcus aureus. All clients are advised not to touch their eyes without first washing their hands with hot soapy water. Infections may occur due to a contaminated environment, client's own bacteria, contaminated and/or improperly preprocesed equipment, or unclean hands touching the area.

Tattooing induces physical damage to the skin, which may cause or promote infections if microorganisms are introduced under the skin during the process. The potential sources of microorganisms include:

• Tap water used to dilute the ink. (Note: Ivonne Sanchez Beauty does not use tap water to dilute its pigments and instead uses steril dilution fluids).
• Contaminated and/or improperly reprocessed equipment or ink (Ivonne Sanchez Beauty adheres to sanitation protocols and does not reprocess single-use products)
• Client’s own bacteria on the skin.
• Unclean hands touching the treatment area.

Potential infections can be caused by bacteria (e.g., Mycobacterium spp. or Staphylococcus aureus), fungi (e.g., Candida endophthalmitis), or even viruses (e.g., human immunodeficiency virus [HIV], hepatitis B virus, hepatitis C virus)”

I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discolouration and swelling.  Fading or loss of pigment can and may occur depending on your skin and lifestyle.  Secondary infection in the area of the procedure may occur, however, if properly cared for is rare. A period of 30 days is required in order to fully heal from the procedure.

4. The minimum or maximum duration of the pigment from the procedure cannot be determined with certainty.

5. The technician and the business performing the service on me will not liable for any damages caused to me or my eyebrows in any way caused by any reason, including allergic reaction, reaction to previous procedures such as previous henna/tint, Microblading or Nano Brows on the brow hair, skin sensitivity, and my failure to follow the Aftercare Instructions. As part of the aftercare, apply a tonic and moisturizer product developed specifically for Microblading or Nano Brows to prolong the results.

I acknowledge by signing below that I have been given the full opportunity to ask any and all questions which I might have about obtaining any permanent cosmetic procedures from Ivonne Sanchez Beauty or any staff or contractor. I also acknowledge that all of my questions have been answered to my full and complete satisfaction. I specifically acknowledge that I have been advised of the fact and matters set out below, and I agree as follows:

  1. 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 the practitioner of any existing sensitivities.
  2. I understand that this is microblading or nano brows and the procedure is either performed with a blade or digital machine.
  3. I acknowledge that complications are possible as a result of the semi-permanent makeup procedure, particularly where aftercare instructions are not followed.
  4. I realize that my body is unique and the practitioner or any of the practitioner’s associates cannot predict how my skin may react as a result of the procedure.
  5. Red heads, blondes and fair skin types will be red, swollen and pigment MAY not retain at all. Future appointments may not be performed. This is up to the discretion of the technician.
  6. Results WILL appear softer as the treated area heals.  The area/s treated WILL NOT look as DEFINED or as BOLD as the 1st procedure. The healing process can take 3-30 days.  Everyone heals differently.
  7. I acknowledge that most procedures require 2 appointments and colour boosts every 1-2 years in order to keep the colour fresh.
  8. I acknowledge and understand that if I have oily/severely oily skin the pigment WILL heal/appear much softer and can look more “solid” due the over-production of oil glands. The pigment WILL fade quicker, look blurred or more “solid”. I accept these risks and would like to proceed. (Addendum required)
  9. Frequent tanning and sun exposure WILL heal darker and fade the pigment quicker.  It is recommended to NOT have a tan/burn (30 days before/after) on your face at the time of your procedure. (Addendum required)
  10. I agree that I will not go on a sun vacation within 30 days of receiving my microblading or nano brow service, and that if I do this voids any assurances that may have been provided to me. A sun vacation will almost certainly ruin the results of microblading or nano brow. I will not be eligible for a touch-up or correction if I have been in the tropical sun.
  11. If you are in Menopause and suffer from hot flashes or your core temperature runs hot, your pigment will/may fade, blur or not retain.
  12. Frequent exercising WILL cause the pigments to fade, blur or not retain at all.
  13. I acknowledge and understand that pigment implanted on darker skin types (i.e. Indian, African American, Filipino etc.) the pigment will appear softer and blend more with your own skin melanin (tones) and will not appear as bold or defined as on lighter skin types and the hair strokes will be less visible.
  14. Alopecia clients: Due to the change in skin texture, pigments WILL heal with a “powdered” look.
  15. 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 later change or remove the result.
  16. I understand that skin altering procedures, such as plastic surgery, implants and/or injections may alter and degrade my permanent makeup. I further understand that such changes are not the fault of the practitioner and/or any of the practitioner’s associates. I further understand that such changes in my appearance may not be correctable through further permanent makeup procedures.
  17. Injectibles such as Botox are not advised during the 2 weeks prior or the 2 weeks following your procedure. Your skin needs time to heal from both microblading and injectibles and these two services should not be booked within at least 2 weeks before or after each other.
  18. Thyroid Conditions and Medicines, WILL prevent the pigment from retaining, fade quickly, blur or change in colour.  I accept these potential risks and wish to proceed.
  19. 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.
  20. I accept full responsibility for determining the colour, shape and position of the brows that will be applied. Once the shape is approved and the pigment is implanted in the skin, it cannot be changed.
  21. I understand that the actual colour of the pigment may vary slightly due to the tone and colour of my skin.
  22. When you leave our studio, the hair strokes are intact.  How your body heals the treated area is 100% out of the control of the technician.  This is 100% your body’s job.  Even when following the aftercare fading, blurring or poor retention can still happen depending on your skin type and lifestyle.  This is NOT the fault of the technician.
  23. If you have had tattoo removal prior to seeing Ivonne, due to scar tissue the pigment may not retain.  Further procedures may not be an option and I understand there are NO REFUNDS and I accept full responsibility and wish to proceed.
  24. If you choose to go with a darker colour for your brows at your initial appt. and later decide that you want to go lighter (lighten hair) it will not be possible to lighten the colour.  Removal may be your only option.
  25. I understand that if I do not adhere to the strict after care instructions, I WILL ruin my results.  The After Care is crucial for optimum pigment retention and results.
  26. I understand that should any other artist or beauty professional work on my brows that this will void any expected results and the process may need to start over again.
  27. Permanent makeup is an ART, NOT a science.  Client results will vary from person to person and using a pencil or powder may or will still be needed.  We have no control over your body’s healing process and each time a procedure is done, the pigment will have less retention due to scar tissue.
  28. Touch ups will not be done any sooner than the required time recommended by the technician.
  29. I understand that at a certain point and as the skin ages, PMU may not be possible.
  30. I have received and read a copy of the aftercare Instructions.
  31. I understand that if I am receiving these services at a discounted rate e.g. as a model in the beauty training program, that the service times and work product will not be the same as a regular service and that I am willing to work with the business or the trainee to support their learning.

I have read and understand the contents of this consent.

Cancellation Policy and Reminders.

All bookings are recorded in an online booking system. This system will send an e-mail confirmation to you of your scheduled appointment at the time that the scheduling is made. The booking system will also send a follow-up reminder e-mail 24 hours prior to your scheduled appointment. Unfortunately, we do not have a telephone reminder service.

A $100 non-refundable deposit is required in order to make a booking for services. This will be applied to your scheduled service subject to the cancellation policy.

All cancellations and appointment rescheduling requests must be made at least 48 hours prior to the start of your scheduled appointment time.

The following events will result in the loss of the $100 booking deposit:

  1. No-shows;
  2. Cancellations without a minimum of 48 hours notice; or
  3. Cancellations with 48 hours notice but where a new booking is not made

I understand and agree to the above cancellation policy.

Customer Satisfaction and Feedback.

If I am unhappy with the results or service, I will not take to the internet to air my grievances of Ivonne Sanchez, Ivonne Sanchez Beauty in any online forum including but not limited to: Google Reviews, Facebook Reviews, Instagram, Facebook, or Twitter. I will instead contact Ivonne privately in order to allow her to work with me to find a solution.

Today's Date: July 3, 2020

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
Client's 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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age

How you found us:

What is the procedure being performed: *

Please record the cost of the microblading or nano brow service.
Area(s) Treated / Treatment Procedure (Please Check):
Eyebrows

What is the date of service: *
For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s).*

SECTION 3: HEALTH QUESTIONNAIRE

To perform the MICROBLADING OR NANO BROW procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure.

COVID-19 Screening Questions

If you have travelled outside of Canada (or have been exposed to someone who a confirmed case of COVID-19) within 14 days of your scheduled appointment you must have subjected yourself to a period of self-isolation and quarantine before you are eligible to receive any services at Ivonne Sanchez Beauty.

Have you travelled outside of Canada within the past 14 days of the scheduled day of treatment?*
No
Yes
If you have travelled outside of Canada (or have been in contact with someone with COVID-19) within the past 14 days have you developed a cough, fever, or experienced difficulty breathing?*
No
Yes
For personal services such as those offered at Ivonne Sanchez Beauty the nature of work performed requires close contact with colleagues and customers (i.e. within 2 metres). These interactions, as well as the need to touch work surfaces and equipment could increase the likelihood that we or you could come in contact with the virus. *
I Agree
Are you over the age of 18? (You must be 18 years of age to receive our services).*
No
Yes
Have you had any aspirin or blood thinning products within the last 7 days?*
No
Yes
Have you taken any mood-altering drugs within the last 8 hours? (e.g. Xanax)*
No
Yes
Do you have any history of cold sores, herpes, or fever blisters?*
No
Yes
Are you sensitive to Latex or Nitrile?*
No
Yes
Have you had a chemical or laser peel?*
No
Yes
Do you have problems with healing?*
No
Yes
Have you had previous problems with tattoos or has your physician advised you not to have a tattoo at this time?*
No
Yes
Are you currently undergoing radiation or chemotherapy?*
No
Yes
Are you currently taking any chemotherapy medications?*
No
Yes
Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)*
No
Yes
Do you wear contact lenses?*
No
Yes
Are you allergic to any metal? (e.g. Can you only wear 14k gold):*
No
Yes
Have you ever had any permanent makeup procedures prior to this appointment with Ivonne?*
No
Yes

If "yes" when?:
Are you taking medication, including immunosuppressive, such as anti-inflammatory or steroids?*
No
Yes
Are you in withdrawal from caffeine products?*
No
Yes
Have you ever been allergic to, or have had an allergic reaction to pigments, dyes, or topical anaesthetics?*
No
Yes
Is there any history of skin diseases or remarkable skin sensitivities?*
No
Yes
Are you*
Are you required to take antibiotics during dental or invasive medical procedures?*
No
Yes
Do you have any allergies? If yes, list in space provided at the end of the form.*
No
Yes
Are you currently taking medication for high or low blood pressure?*
No
Yes
Will you work out on the day of treatment?*
No
Yes

No. of times you work out weekly
Do you currently have and/or have had in the past, and/or have you experienced any of the following:
Hemophilia
Do you have problems with healing of wounds?
Diabetes mellitus (diabetes)
Hepatitis A, B, C, D, E, F
HIV +
Eczema
Are you prone to herpes?
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning (anticoagulants)?
Are you pregnant?
Have you received microblading, nano brows, or tinted your eyebrows in the last 6 months using brow henna, henna or tint/dye?
Oily Skin

Please list any skin diseases :

Please list any autoimmune diseases:

Please list any related medications taken on a daily basis:

Please explain any question marked "YES", list any other medical conditions or allergies (including allergies to cosmetics or cosmetic ingredients), and list all your medications:

Additional Questions:


Planning on having Facial Plastic Surgery
 Date surgery scheduled:

Botox (date of last treatment)
Have you consumed drugs or alcohol within 24 hours of the treatment?*
No
Yes
Did you in the last 14 days undergo surgery, in which you were you exposed to radiation, or any other medical interventions?*
No
Yes
Have you applied Retin-A, AHA ("alpha-hydroxy acids"), or exfoliated your brows within the past 72 hours?*
No
Yes

Addendum to Consent.
Tan Skin

I understand that having tan skin at the time of the appointment is a contraindication in permanent makeup.  Tan skin will bleed, possibly heal darker and can or will fade to an ashy colour as the tan fades.  The pigment CAN and WILL heal more "solid" or "powdered".  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or may not happen.

NO guarantees have been made to me as to the final results.

I fully understand and accept the above-mentioned risks and will hold Ivonne Sanchez (Ivonne Sanchez) harmless if mentioned risks do occur.  I understand that appointments will not be made any sooner if the above-mentioned risks occur and there may be a chance that any future procedures may not be performed.  This is left up to the discretion of Ivonne.

Against the recommendation of Ivonne Sanchez Beauty, I wish to proceed anyway.

Addendum to Consent: Tan Skin*

Addendum to Consent.
Oily to Severely Oily Skin and Large Pores

I understand that having oily/severely oily skin or large pores are contraindications in permanent makeup.  Due to the over-production of the oil glands in the skin and the size of the pores, the pigment CAN and WILL heal more "solid" or "powdered" looking.  The hair strokes can look thicker, appear blurry under the skin, change in colour, fade prematurely or not retain at all.   These are all potential risks that I accept may or can happen. 

NO guarantees have been made to me as to the final results.

I fully understand and accept the aforementioned risks and will not hold Ivonne Sanchez Beauty accountable if the aforementioned risks or outcomes occur.

Against the advice of Ivonne Sanchez Beauty I wish to proceed anyway with microblading and or nano brows. 

I understand that appointments will not be made any sooner if the above risks occur and there may be a chance that any future procedures may not be performed.  Any decision is left to the discretion of Ivonne Sanchez Beauty.

Addendum to Consent: Oily to Severely Oily Skin and Large Pores*

SECTION 4: USE OF LIKENESS AND RELEASE (PHOTOS & VIDEO)

By participating as a client, I permit, authorize, and license the technician(s) and the Business and their employees, officers, directors, contractors, and agents of each and all of them ("Authorized Persons"), to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use my image, likeness, and appearance, and all materials created by or on behalf of my participation that incorporates any of the foregoing ("Materials") on a perpetual basis throughout the world and in any medium or format whatsoever now existing or hereafter created for publicity, advertising, and marketing purposes, and for any purpose they deem reasonably appropriate, without further consent from or royalty, payment, or other compensation to me. I agree that all right, title and interest in and to all such Materials is the exclusive property of the Authorized Persons. I understand that the Authorized Persons may keep or use the Materials now and in the future. I understand that although the Authorized Persons will endeavour to use my image, likeness, and appearance in accordance with standards of good judgment, they cannot warrant or guarantee that any further dissemination of my image, likeness, and appearance will be subject to their supervision or control. Accordingly, I release the Authorized Persons from all liability or responsibility that may arise from the acts that I have authorized or consented to in this Section.*
No
Yes

SECTION 5: GENERAL RELEASE AND WAIVER

I recognize and acknowledge that there are certain risks of personal injury or property damage related to my participation as a client, and I voluntarily agree to fully assume all of these risks, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with the application by the technician of brow lamination and/or colouring to my eyebrows using the Brow Lamination technique, including, but not limited to, injuries, damages and losses arising out of negligent supervision, tort, contract, products, or any other theory of recovery. I, for myself and my heirs, assigns, personal representatives, and next of kin, expressly waive and release any and all claims, now known or hereafter known, against the Business, and their employees, officers, directors, contractors, and agents of each and all of them (collectively, "Releasees"), on account of personal injury or property damage arising out of or attributable to my participation as a client, whether arising out of the negligence of any Releasees or otherwise. I covenant not to make or bring any such claim against any Releasee, and forever release and discharge all Releasees from liability under such claims. All matters arising out of or relating to this waiver and release shall be governed by and construed in accordance with the internal laws of Ontario without giving effect to any choice or conflict of law provision or rule (whether of Ontario or any other jurisdiction). Any claim or cause of action arising under this waiver and release may be brought only in the federal and Provincial courts located in Ontario, Canada and I consent to the exclusive jurisdiction of such courts. I understand that this waiver and release is intended to be as broad and inclusive as permitted by law and that if any portion hereof is held invalid, I agree that the balance shall continue in full legal force and effect. I further agree that if this waiver and release is not valid in Ontario, Canada, it shall be construed as a covenant not to sue anytime, anywhere and for any reason. *
I Agree
I HAVE READ THE INFORMATION IN THIS WAIVER THOROUGHLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT AND I AM SIGNING THIS WAIVER AND RELEASE FREELY AND VOLUNTARILY. *
I AGREE
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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