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  • CLIENT CONSENT / MEDICAL FORM

    CLIENT CONSENT / MEDICAL FORM

    Permanent Makeup Services

  • This form is designed to give required information needed to make an informed decision on whether or not to undergo a Semi-Permanent Makeup procedure. If you have questions, please do not hesitate to ask.

    • This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing.  
    • All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are strictly adhered to.  
    • Generally, the results are excellent. It is usual to expect a touch-up after the healing is completed.  
    • Initially the color will appear much more vibrant or darker compared to the end result. Usually within 14 - 28 days, the color will fade 15 - 20%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years. 
    • Please review the risks, hazards and complications listed below. Not all clients will have the same healing process or results. We are not liable if your skin does not retain the pigment due to skin type, or any factors outside of our procedural processes. 
  • Date of Birth*
     / /
  • If we call you at home, do you want confidentiality?*
  • May we call you at work?

  • EMERGENCY CONTACT:
    THEIR PHONE NUMBER IS: .

  • Procedure(s) desired:*
  • Are you? (Check ALL that apply)*
  • Brow Lamination History

    Brow Lamination History

  • Have you ever had your brows laminated?*
  • Have you tinted your brows in the last 6 months?*
  • Have you ever had an allergic reaction to hair dye?*
  • Have you ever had an allergic reaction to a perm?*
  • Are your eyebrows microbladed?*

  • If Yes, when: *

  • Rows
  • Rows

  • The client consents * or waives * their right to an allergy test prior to the permanent tattoo procedure to determine allergic or other reactions to the pigments being used by the Practitioner.

  • GENERAL MEDICAL QUESTIONS

    GENERAL MEDICAL QUESTIONS

  • Do you have? (Check ALL that apply)*
  • Have you use? (Check ALL that apply)*
  • Have you had? (Check ALL that apply)*
  • Do you practice outdoor activities? (Check ALL that apply)*
  • DATE*
     / /
  • INFORMED CONSENT TO PROCEDURE

    INFORMED CONSENT TO PROCEDURE

    (please initial)

  • *I absolutely understand and accept that such a procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed.


    *I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them.


    *Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color.


    *I understand that the color selection and color results in all procedures are not an exact science.


    *I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restylane and I assume this responsibility.


    *I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics.


    *If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.


    *I understand that this procedure will fade and this fading can alter the original pigment color and that this determines that it is a time for a touch-up visit.


    *I realize this is an elective cosmetic procedure and is not medically necessary.


    *It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment.


    *I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent makeup dark or even black.



    I agree to inform my esthetician or anyone operating such that I have permanent make up.


    *I give my consent to Arch Angels NYC + NJ to confer with my physicians for medical information required for the safety of my procedures.


    *I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner.


    *I am aware that if an infection occurs after I have received Permanent Cosmetics to seek help with my primary physician or an emergency room, immediately.


    *I am aware that touch-ups are NOT included in the cost of any initial service. 

    I am aware that the Final Sale is NON-REFUNDABLE.

  • Are you pregnant or nursing?*
  • Have you had COVID-19 vaccine?*

  • ACCEPTANCE AND ACKNOWLEGEMENT

    I have read and understand these risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and my questions have been answered.  

    **Please read all questions thoroughly before signing**

  • PHOTOGRAPHY RELEASE CONSENT

    PHOTOGRAPHY RELEASE CONSENT

  • We would like your permission to use these photos for advertising. For example, in portfolios, online and in print ads, etc. Please be advised that no artist will be authorized to share your pictures on their personal social media accounts. Photos will only be publicized on the company's social media accounts. Your consent is necessary regarding this.

  • Please check the box and indicate if you would like your photos used or not regarding any and all advertising/marketing under Arch Angels NYC / NJ ONLY.*

  • Video Surveillance Disclosure & Consent

    Notice of Electronic Monitoring
    In accordance with New York Labor Law § 203-C and applicable New Jersey privacy statutes, Arch Angels NYC & NJ utilizes video surveillance on these premises to ensure the safety of patients, staff, and visitors, as well as to protect company property.

    • Scope of Monitoring: Cameras are located in public areas, hallways, entrances/exits, and designated treatment areas.
    • Privacy Protections: Surveillance is strictly prohibited and not conducted in areas with a high expectation of privacy, including restrooms, changing rooms, or employee locker rooms.
    • Audio Recording: In compliance with state wiretapping laws and "one-party consent" regulations, video surveillance in treatment areas is conducted without audio recording to maintain the confidentiality of patient-provider communications.
    • Purpose: These recordings are used solely for security, safety, and quality assurance purposes.

  • HIPAA Compliance: Photo/Video Storage & Extraction

    Storage and Security of Digital Media
    Any video or photographic footage that captures a patient’s likeness or identifies their medical condition is treated as Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA).

    • Secure Storage: All digital media is stored on encrypted servers with restricted access. Access logs are maintained to track who views or extracts footage.
    • Retention Policy: Recordings are retained for a period of 90 days, after which they are permanently deleted or de-identified, unless required for an ongoing investigation or legal proceeding.
    • Transmission: Any extraction of video for external use (legal requests, insurance, or transfers) will be performed using secure, encrypted channels.
    • Patient Rights: You have the right to request an accounting of disclosures regarding your recorded image, provided the footage has not been routinely destroyed per our retention policy.
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  • Date*
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  • Should be Empty: