New Client Consultation Form

AALIYAHS BEAUTY & BROWS CONSENT FORM
Clients Full Name*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Referred By

First NameLast Name
Select for consent*

I hereby authorize Ayesha to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises in the course of the procedure(s) I further request and authorize her to use her full judgement and do whatever he/ she deems advisable and necessary in the circumstances.I understand that semi-permanent and permanent cosmetic enhancement is an advanced form of tattooing.I accept responsibility for determining the color, shape and position of the enhancement as agreed during the course of my consultation.I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs.I am aware that a sensitivity reaction to anesthetics can occur and accept all responsibility if allergic response occurs.I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over the course of 1-3 years. Even though the color has faded, the pigment will stay in the skin indefinitely and may leave a light residue of color.I understand that dyes, inks and pigments are not approved by the Food and Drug Administration (FDA) and the health effects are not known.I accept that the highest standards of hygiene are met, and that sterile disposable needles are used for each individual client, procedure and visit.I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I may need to return for a touchup procedure that is included in the initial price.I understand that the touchup procedure, if required, will be performed 4-8 weeks after the initial procedure and that after the 8 week period I will be charged an additional fee for any procedures. I will book the appointment when it is convenient for both parties.I understand that semi-permanent cosmetic enhancement is an invasive procedure and the infusion process can be uncomfortable.I understand that loss of any eyelashes during the healing of permanent cosmetic eye enhancements will result in new eyelash growth over a 4 month period and that eyelash loss is rare and minimal. (Eyeliner specific)I understand that in rare cases that corneal abrasion can occur during eyeliner procedures. (Eyeliner specific)
I am aware that the result of the procedure is determined by the following:*

MedicationSkin Characteristics - i.e. dry/oily/sun-damaged Natural skin undertonesAlcohol intake and smokingGeneral stressA compromised immune systemPoor dietPost procedure care treatment
*

I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-2 days dependent on lifestyle. In some cases bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited for up to two weeks following the infusion process.I understand that immediately after the procedure the enhancement can be 40% to 60% darker than the desired result and can take between 4-10 days to lighten. I understand that the true color will be visible 1 month after each application, and that the color may vary according to skin tones, skin type, age and skin conditions. I appreciate that some skins accept color more readily than others and no guarantee of an exact effect or color can be given.I am aware that if I have had a previous outbreak of cold sores/herpes and receive a lip enhancement I may have an outbreak again following the procedure. I have been made aware that anti herpes medication is available over the counter or on prescription and has been shown to prevent or minimize such outbreaks.I am aware that that if I have had a previous eye disorder or eye infection and receive an eyelash enhancement, the disorder may reoccur again. I agree to use the correct medication to prevent such a disorder reoccurring. (eyeliner specific)I am aware that even though my vision is not affected by permanent cosmetic eye enhancements I may wish to have someone drive me home. (Eyeliner specific)I understand that I may experience dry lips for up to two weeks following permanent cosmetic lip enhancement. (Lip specific)I understand that scar camouflage procedures require skin color-matching tests before the procedure commences and will not give the result of an undetectable scar.I understand that there are few effective methods for pigment removal. Laser removal has proven successful, however is a process.I agree to inform my doctor of my permanent cosmetic enhancement if I require a MRI scan within a 3 month period of receiving the procedure.I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner. I understand that infection and possible scarring can occur if I do not adhere to the said instructions.To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol.For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s). I give my consent for before and after pictures to be used for marketing.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not give the current limits in virus testing.*

by checking this box I understand and accept this statement.
I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL.I declare that I give my full consent to the tattooing being carried out by the aforementioned practitioner. I confirm that potential complications, e.g. infection and swelling, for the procedure undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed.I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e. 18 years old for tattoos) and that I am not currently under the influence of alcohol or drugs.’I have read and understood the above information.*

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Client Signature*
Medical Health Form
Name

First NameLast Name
Address*

Street Address

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CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
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Occupation:
List all the medications you have been taking in the last 6 month:
Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?
Have you received chemotherapy or radiation treatment in the last year?
Name of Doctor:
Surgery:
Allergies: have you ever had an allergic reaction to any of the following:

Antibiotic ointments MedicationDrugsPaintsLatex Rubber Metals Foods CrayonsNutsHair dyes LidocaineGlycerine
Anesthetics (which ones)
Other allergies (list)
Have you had a dental injection to numb your mouth?
Are you presently pregnant or breast feeding?
MRI scan scheduled in the next 3 months
Laser or IPL scheduled in the next 3 months
Do you give blood?
Prior to dental procedures do you receive antibiotic therapy?
Please fill out the following table with a tick to indicate if any of the following relate to yourself.

Abnormal Heart ConditionMitral Valve ProlapsedRheumatic FeverArtificial Heart ValvesHaemophiliaHigh Blood PressureCirculatory ProblemsEpilepsyThyroid DisturbancesKidney DiseaseStomach Ulcers CancerStrokeProsthetic Hip or Joint HepatitisSeizuresCataractsDry EyesAlopeciaWatery EyesEyelid SurgeryTrichollomaniaCold Sores (herpes simplex)Gore-Tex Implants/Silicone Injections Fat InjectionsBotox EnhancementPalpitationsHeart MurmurPacemaker AnaemiaProlonged BleedingLow Blood PressureDiabetesFainting Spells or DizzinessLiver DiseaseGlaucomaTumours, Growths or Cysts TuberculosisHIVSystemic LupusErythematosus ShinglesImpetigoBlurred VisionDo you suffer from eye InfectionsOccular HerpesContact LensesChapped LipsRecent Hair LossAuto immune conditionsOther TattoosBruise or Bleed EasilyUse of Sun bedDermal Fillers i.e restylaneDo you have Healing ProblemsDo you scar in a raised manner?Do your scars heal a darker colorKeloid ScarsAcutance within 6 monthsSteroids within 6 monthsDate of last eyelash/ eyebrow tintChemical or laser peel within 6 monthsRetin A within 6 monthsAHA preparations within last 2 weeksSensitivity to CosmeticsDo you tan regularly?Asthma
Chart notes for:
SEMI-PERMANENT BROW AFTERCARE
- Expect slight swelling and a little redness in the immediate area.
- Keep the area lightly moist using a Q-Tip with sterile Aquaphor 1or 2 times a day (morning and night) for 7-10 days. If slight crust appears on pigmented surface, do not force removal by picking or scratching!! (You will remove pigment along with crusting) Brows are not considered healed until all crusting has exfoliated.
- Avoid washing treated area for the first 24 hours.
- After the first day wash with mild soap and water and pat dry.
- Avoid eyebrow pencils and do not put powder on the brows (to lighten)
- Avoid tinting of brows for 3 weeks following the procedure.
- Avoid hot, steamy, long showers. A thin coat of Aquaphor over the pigment is a good idea before showering.
- The procedure may have some peeling on or around the 3rd day. This is a normal process of healing for some clients. Do not Pick... picking can cause scarring and loss of color.
- The application of permanent cosmetics can be a 2 step procedure. Do not judge your procedure while in the healing stage. It may require a touch up.
- Don’t be alarmed if color comes off on to the Q-Tip when applying topical ointment. This is normal.
- Avoid the gym or sweating for 3-5 days following the procedure.
- Avoid sun for 7-10 days following the procedure.
- Avoid chlorine pools, saunas and jacuzzis.
- Avoid makeup on pigmented area until healed.
- Avoid Retin A, Glycolic Acids, Aloe, and Vitamin E products.
- No Terry Towels on pigmented areas.
- No Gardening for the first 3-4 days to prevent possible infection.
- If you are planning a chemical peel, MRI, or other medical procedures inform them that you have had an iron oxide cosmetic tattoo.
- You must wait 1 year after any tattoo to give blood.
- Lasers can cause pigment to turn black. Avoid the procedure site.
- If any signs of infection occur, abnormal swelling, redness or pain associated with the procedure, call you physician (and please give us a call).
- After you have healed, use a good sunscreen daily to help prevent premature fading of all procedures.
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AALIYAHS BEAUTY & BROWS CONSENT FORM

Medical Health Form