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LE BEAUTY

SEMI PERMANENT MAKEUP

I am over the age of 18 and desire Leticia Feijo to perform the elective cosmetic pigmentation procedure understanding that this procedure is for cosmetic purpose only and not for heath reason. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure(s).

April 28, 2024


I also understand that the semi permanent skin pigmentation procedure carries with it the possible complication and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, inconsistent color, fanning or fading of pigments and or allergic reaction to any products used. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. Laser treatments may also compromise the semi permanent cosmetic application. I fully understand as with all such procedures that this is not a science but rather an art and that anything can go wrong. I request the semi permanent skin pigmentation procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s).

 

April 28, 2024

For the purpose of documentation, I also consent to the taking of before, during and after photographs / videos of said procedure (s) which become the technician's sole property and may or may not be used for whatever purpose deemed necessary including using pictures for social media and advertising publications. Understanding the permanent skin pigmentation procedure, the permanency of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize Leticia Feijo to perform the semi permanent skin pigmentation procedure(s).

 

April 28, 2024


I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

April 28, 2024


Client Treatment Consent and Release

I acknowledge that beauty treatments, the practice of skin care, and the practice of massage, including, but not limited to, micro ablation, microdermabrasion, waxing, electrolysis, facial toning, permanent cosmetics, body treatments, ionization, laser treatments, tattoo removal, vein treatments, brown spot removal, BOTOX, Collagen, Dermal Fillers, PRP Injections, Sclerotherapy, Mesotherapy, Dermaplaning, and various other beauty procedures is not an exact science and no specific guaranties can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference.

April 28, 2024

 

I also understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage, scarring, infection, change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance.

April 28, 2024

 

Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the company and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.

 

April 28, 2024 


I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may effect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.

 

April 28, 2024



First Client’s Name

First Name*

Last Name*

Phone*
First Client’s Date of Birth*
First Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



First Client’s Signature*
Second Client’s Name

First Name*

Last Name*
Second Client’s Date of Birth*
Second Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Third Client’s Name

First Name*

Last Name*
Third Client’s Date of Birth*
Third Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Fourth Client’s Name

First Name*

Last Name*
Fourth Client’s Date of Birth*
Fourth Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Fifth Client’s Name

First Name*

Last Name*
Fifth Client’s Date of Birth*
Fifth Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Sixth Client’s Name

First Name*

Last Name*
Sixth Client’s Date of Birth*
Sixth Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Seventh Client’s Name

First Name*

Last Name*
Seventh Client’s Date of Birth*
Seventh Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Eighth Client’s Name

First Name*

Last Name*
Eighth Client’s Date of Birth*
Eighth Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Ninth Client’s Name

First Name*

Last Name*
Ninth Client’s Date of Birth*
Ninth Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Tenth Client’s Name

First Name*

Last Name*
Tenth Client’s Date of Birth*
Tenth Client’s Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
I certified that I am 18 years of age or older
Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?
Do you have any allergies to latex?
Do you take Zovirax, valtrxor Famvir?
Do you have any kind of heart trouble?
Are you allergic to or ever had any reaction to Polysporin, Bactarin, Neosporin, A&D, Vaseline or topical healing ointments or products?
Are you allergic to Novocaine or any caine anesthesia?
Are you prone to or have any Keloid scars?
Do you were contact lenses?
Have you had botox in the last 3 weeks?
Do you have excessively oily skin?
Do you have any skin conditions such as eczema?
SKIN TYPE Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s): *
Black skin; rarely sun sensitive
Common skin type; fair; eye and hair color vary
Fair skinned; light hair, light eyes.
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Very fair skin; blonde or red hair; light colored eyes; freckles common

Are you presently taking any medication? List:

Are you allergic to any foods or medications? List:

Are you under a physician's care? What for?
Do you agree to the fees discussed?*
Yes

I fully understand that a deposit of a $50 is required to schedule an appointment, in the event of cancellation of procedure with less than 48 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results.

The touch up procedure MUST be scheduled between 30 to 40 days, and a fee of $59 will be charged. If the client does not make an appointment or does not show up for the scheduled appointment without previous notice, an additional fee of $50 will be charged. If a second touch-up is necessary (up to 60 days after the first session) the $59 fee will be charge again.

If the first touch up session is between 40 to 60 days, the fee will be $100.

All touch up scheduled after 90 days, from the procedure date will be charged full price.

There is a possibility of an allergic retain of pigments. A path test if advisable however it does not ensure a client will not have an allergic reaction.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)

If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: Deionized water, non-ionic surfactant, vegetable glycerin USP, propylene glycol USP, and non-toxic pigments/iron oxide, lakes, alcohol, Glycerin and distilled sterilize water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

Laser treatments or ANY kind of facial injections may also compromise your permanent makeup application.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.

I also understand that this procedure is semi permanent.

I will follow all after Care instructions explicitly. Failing to do so will compromise my final results.

Please select all that apply: I request permanent cosmetic make-up procedures
Eyeliner
Lip Blush
Microblading
Ombre Brows

Medical Consent and Procedure Chart

If you are now taking or recently have taken any of these drugs, please select below. You may need a physician's release prior to your procedure.
Antibiotics
Accutane
Seizures meds
Meds for mood change
Anticoagulants
Diabetic meds
Heart meds
Tranquilizers
Steroid preparations
Blood thinners
Blood pressure meds
Meds for depression
Please select if you have or had recently any of the following. You may need a physician's release prior to your procedure.
Accutane
Allergies to make-up
Anemia
Blister on lips
Chemical peels
Cortisone
Diabetes
Epilepsy/seizures
Excessive bleeding
Gortex
Heart conditions
Hepatitis/HIV
Hyper-pigmentation
Hypertension
Keloid or hypertrophy scars
Herpes
Autoimmune disorders
Refractive eye surgery
Stroke
Trichotillomania
Could you possibly be pregnant?**
No
Yes
Novocain, Lidocaine or any topical anesthetics?**
No
Yes
Do you have any allergies to any medication or latex?**
No
Yes
Have you ever had any permanent cosmetics applied?**
No
Yes

If so please describe
Did you sign any Consent or Release forms?**
Yes
Was pigment disposed of after your procedure was complete?**
Yes

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures (s) which is to be performed at my request according to this consent were filled in before I signed this statement.



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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