Client Medical and Consent Form

Timeless Artistry Permanent Makeup

3035 White Bear Ave E, Suite 22, Maplewood, MN 55109
Client Information
Your first and lastname

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Emergency Contact Name
First Name & Last Name
Emergency contact Phone Number
How did you hear about Timeless Artistry Permanent Makeup

Friends/FamilyFacebookInstagramGoogleOther
Have you any permanent makeup procedures before consulting with Timeless Artistry?

NoYes
What service(s) are you booking for?

Powder EyebrowLipsTraditional eyelinerWinged EyelinerLash enhancement EyelinerRe-touchOther
If you have recieved work from another artist, it would be considered a cover-up. There is an additional cover-up fee $100. This fee is added on top of my service fee.
What is your skin type? Can select more than one (1).

Dry SkinOily SkinCombination SkinSensitive SkinMature SkinOther
Medical History

To avoid unforeseen complications, please answer truthfully and accuratly the following.

	Yes	No
Any other health conditions not listed above?

Please list any allegeries that you have
Please list any medications, vitamins, or supplements you are taking
If you answered yes to any question above, please explain in the box below.
I agree that my medical health history is true and accurate to the best of my knowledge.

Clear
By signing this, I certify that I have that my medical health history is true and accurate to the best of my knowlede.
First Name Last Name
Signature Date

Possible risks, hazards, and complications
Permanent Make-up

Permanent make-up is a form of tattoo. It uses a hand tool or machine to insert pigment under the skin. Although the pigment is inserted in the upper layer of the dermis, it is permanent. It does fade with time.

In order to remove ink from under the skin, it maybe removed using a laser or surgical procedure.

Pain

There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.

Infections

Although infections maybe rare. In a the case there is a suspician of infection, you should see your primary care doctor.

Redness, Swelling & bruising

Redness, swelling and bruising may occur. Any redness, swelling and brusing should typically disappear 1 - 5 days. You may apply ice pack to the area to help with the swelling and bruising. Please follow the instructions on the ice pack.

Some people may not have any redness, swelling, and/or bruising.

Anesthetics

Topical anestheics is used to numb the area serviced. Topical anesthetics come in either cream or gel form. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and Epinephrine are ingredients in these topical anesthetics.

If you are allergic to any of these, INFORM ME IMMEDIATELY.

Asymmetry

Every effort will be made to avoid asymmetry but our faces are not symmetrical.

Before starting the procedure, the service you recieve will be mapped out. You will approve the shape before the service begins.

Uneven pigmentation

You may experience uneven pigmentation during your healing phase. This may be from the anatomy of how your skin heals,

Eyebrow Services

As your eyebrow heals, it may shrink up to 20-30 % in size. The color may fade up 30 - 40 %.

Eyeliner Services

As your eyeliner heals, it may shrink up to 40% in size. The color may fade up 30%.

Lip Services

If you are prone to cold sores or fever blisters, there is a high possiblity that you will get them. It is recommended that you call your doctor for an antiviral presciptioin to help prevent this from occuring.

As it heals, the color can fade up to 40%. There is a possiblity of shrinkage up to 20 - 30 %.

Allergic Reaction

There is a small possiblity of an allergic reaction. You have a choice to do a patch test a week prior to your appointment.

A reaction can occur at anytime in your life even if there is no reaction to the patch test.
Would you like to schedule a patch test?

YesNo
By signing this, I certify that I have read (or have read to me), agree, and understand the possible risks, hazards, and complication of recieving permanent makeup services.
First Name Last Name
Signature Date

Consent for Permanent Makeup

PLEASE READ AND SIGN WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING.
In consideration of recieving {whatIs}, from Rainbow Xiong, the practioner at Timeless Artistry LLC.

I, {enterYour}, confirm the following by initialing each applicable item below:
Initial Here   I understand that a tattoo is considered permanent and may only be removed with a surgical procedure.
Initial Here   I understand that any effective removal of a tattoo may leave scarring.
Initial Here   I am the person on the legal ID presented as proof that I am at least 18 years of age.
Initial Here   I am the person on the legal ID presented as proof that I am at least 18 years of age.
Initial Here   I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion.
Initial Here   I acknowledge the information I provided in the medical questionnaire is complete and true to the best of my knowledge.
Initial Here   The body art described or shown on this form is correctly placed to my specifications. If applicable, I have also confirmed all spelling and grammar necessary in the procedure.
Initial Here All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure I am about to receive.
Initial Here I understand the restrictions associated with this body art procedure as explained by the technician.
Initial Here I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Initial Here   I am aware of the signs and symptoms of infection, including but not limited to, redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent draining from the procedure site.
Initial Here  I understand there is a possibility of getting an infection as a result of receiving body art.
Initial Here   I agree to follow all instructions concerning the care of my body art procedure and that any touch-ups needed due to my own negligence will be done at my own expense.
Initial Here   I understand that there is a chance that I might feel lightheaded or dizzy during or after being tattooed.
I, {whatIs}, have been fully informed of the risks of body art including but not limited to infection, scarring, and allergic reactions to items associated with body art procedures.

Technician will not perform the body art procedure if you fail to complete or sign this form.

Further, technician may decline to perform a body art procedure if the client has any identified health conditions.

Having been informed of the potential risks associated with this body art procedure, I still wish to proceed with the body art application and I assume any/all risks that may arise from body art.
Client Signature Signature Date
________________________________________________________________________________________
On the day of your appointment, technician will review this form with you.
Technician Signature Signature Date
Technician: Rainbow Xiong, Body Art License #: 313107

Photography and videography Release Consent
Your BEFORE and AFTER photos/videos taken are kept on file.

Timeless Artistry LLC would like your permission to use these photos/videos for marketing, advertising, and usage on social media platforms.

Please indicate below with your signature if you give Timeless Artistry consent to use your photos/videos for marking and advertising purposes.
Yes, I give my consent to Timeless Artistry to use my photos and/or videos. No, I do not give my consent to Timeless Artistry LLC to use my photos and/or videos.
{whatIs}
Signature Date

Timeless Artistry LLC Policies

Please read thoroughly and carefully and initial or sign where indicated.
Type a label   Non-Refundable Deposit Fee
There is a $100 non-refundable deposit fee. This deposit fee is to secure my appointment slot. I understand that the non-refundable deposit fee is included in my service.

Type a label   Services are FINAL SALE
This transaction is final; no substitutions, exchanges or refunds.
I understand that for whatever reason I change my mind and decide not to obtain all sessions I paid for there is a no money back guarantee.

Type a label   Complimentary re-touch
I understand that I recieve one complimentary re-touch appointment with my service(s).
The complimentary re-touch appointment must be scheduled on the day of my initial appointment.
The complimentary re-touch is to be scheduled within 8 weeks after my initial appointment. If scheduled outside the 8 weeks, I am responsible to pay my re-touch service(s) at the current rate.

If any of the following below occurs, I will lose my one complimentaty re-touch and I will be responsible to pay my re-touch services(s) at the current rate.
- Cancel my re-touch appointment
- giving less than 3 days notice to reschedule my re-touch appointment
- arriving 15 minutes or more to my re-touch appointment.
- Missed my appointment
Type a label Mask Requirement
Masks is REQUIRED before entering the salon. I will appropriately wear my mask to cover my nose and mouth. I will wear my mask for the entire time of my appointment.

For lip service appointments:
I must wear my mask entering the salon. Due to the nature of the service, I understand that my mask will not be worn when my lip service is performed. I will only remove my mask when instructed to do so by the Permanent Makeup Artist.

Type a label Covid-19
- If you are experiencing any
- If I have recieved or plan to recieve the Covid-19 vaccine, I must complete the following:
  - must complete Pfizer or Moderna vaccine series
  - There is 2-week waiting period to schedule my {whatServices}.
Type a label   No guest(s) policy
No guests are allowed to accompany me to my appointment. This is to maintain a sterile environment and to prevent any possible cross contaminiation, distractions, interruptions, and spread of Covid-19.

Type a label   Late Arrival Policy
If I am late to my appointment 15 minutes or more, my appointment will be considered cancelled and no-show.
I will forfeit my Non-refundable deposit fee.
I will be responsible to pay the full amount of my service(s) to secure my next appointment slot(s).

Type a label   Cancellation Policy
If I cancel my appointment for any reason, I will forfeit my non-refundable deposit fee.
A FULL payment of my service(s) is required to secure my appointment slot(s).

Type a label   Reschedule Policy
If I need to reschedule my appointment(s), I must notify Timeless Artistry/Rainbow Xiong 3 days (36 hours) or more in advance to reschedule my appointment.

If I give notice less than 3 days (72 hours), I will forfeit your deposit fee.
A full payment of my service(s) is required to secure my next appointment slot(s).

By signing this form, I am acknowledging that I have read and fully understand the policies where I initialed above. Any questions I have regarding the policies have been
answered and explained to me.

{whatIs}
Client Signature   Date
Should be Empty:

Timeless Artistry Permanent Makeup

Client Information

Medical History

Possible risks, hazards, and complications

Consent for Permanent Makeup

Photography and videography Release Consent

Timeless Artistry LLC Policies