Permanent Makeup Consultation Form
Name
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First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure/Service
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Microblading
Combo Brows
Ombre or Powder Brows
Wild Eyebrows
Dark Circles Camouflage
Brazilian Stretch Marks Camouflkage
Scar Camouflage
Full Scalp Micropigmentation
Scalp Scar Camouflage
Beauty Marks or Freckles
Lip Blushing
Eyeliner or Lash Enhancement
BbGlow
Aureola 3D
Eyebrow Lamination
Eyebrow Hair Growth
Permanent Makeup Removal
Lash Lift and Henna
Eyebrow Shaping and Henna
Are you currently taking any medications?
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Yes
No
What are the medications you're currently taking and what is their purpose?
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Are you wearing contact lenses?
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Yes
No
Do you have any implants?
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Yes
No
Do you have any Botox or other injectables?
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Yes
No
Please check below if you have the following medical condition:
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Rows
Yes
No
Cancer
Hyperpigmentation
Keloid
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Cancer
Venereal Disease
Asthma
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia
Allergies
Autoimune Diseases
Infectious Diseases/High Temperature
Cardiovascular Problems
Pregnancy or Breastfeeding
Wound Healing Problems
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
*
Have you had this service done before?
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Yes
No
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
TV Commercial
Online Ads
Posters/Banners
Magazines
Newspaper
Referral
Other
Your Instagram or Facebook
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I consent to photographing, filming, recording, and/or digital imaging of the treatment to be performed and usage of the photos for the advertising purpose.
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Yes
No
I consent to photographing only of the part undergoing the service, nothing else (example: only the eyebrows, or the lips, or the eyes, ect.)
I would like to send a picture so the Artist can evaluate before the service desired.
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Acknowledgment
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I understand that this procedure cannot guarantee 100% expected results.
I understand that sun, tanning beds, pools, some skin care products and medications can affect my final microblading result.
I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m scheduled for an MRI (Magnetic Resonance Imaging) for the camouflages services.
I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch up session within 6-8 weeks of initial procedure for all PMU services.
Aftercare instructions have been explained to me which I will follow to the best of my ability.
I am 18 or older, I am not under the influence of drugs or alcohol, I am not pregnant or nursing, and I consent to receiving the chosen procedure.
I understand that Retin A, Renova, Alpha Hydroxy, and Glycolic acid must not be used on the treated areas. They will alter color.
I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.
I understand that permanent cosmetics are a form of tattooing.
I confirm that a healing period is required before the next or before the touch-up treatment for PMU services.
I understand that a certain amount of discomfort is associated with this procedure and that is swelling, redness and bruising.
I understand that there might be an allergic reaction.
I understand that I might experience minor bleeding, swelling, and redness for all camouflages and PMU services.
I understand that infection is possible if the after care is not followed properly.
There will be no refunds for this elective procedure(s).
During the healing process the color of the PMU/camouflage will change. All information is provided in the after care kit.
Quality of the skin is different in clients, the skin differently reacts to pigment insertion, hence there is no guarantee for the treatment success.
How long it will last, minimum or maximum duration, cannot be precisely determined, nor can a guarantee on the performed treatment be made. First refreshment is done four weeks after the procedure. The oily skin requires more refreshments.
Permanent make-up always leads to the skin injury. It is thus important to carefully and gently nourish the skin after the treatment to ensure healing without complications. Inadequate after care during the healing period may lead to poor results and the Artist does not bear responsibility for that.
Depending on the skin structure, it should be known that change in color intensity is possible and that one or more re-touch appointments will be required.
I release the center for any liabilities related to the treatment and result specifically allergic reactions and applied pigmentation.
I confirm that I agree that the Artist collects, processes and uses my personal data obtained when signing consent, which may include the transmission of such data outside the territory of the State in which the treatment is performed.
I confirm that I agree that Artist may give my personal data for use and / or processing to other persons such as his employees and all other persons engaged outside the employment relationship to assist Artists in performing their activities.
I am aware of the fact that the Artist will take measures to ensure that such persons protect the confidentiality and security of personal data, and that my personal data is addressed in part and solely for the purpose of achieving the purpose of giving consent-for the purpose of performing the treatment.
I autorize Kauana Moras Rocha to perform on my body the procedure desired.
I confirm that I have read and understand this Consent Form and I agree to be bound by it. I agree that all the above information is true and accurate to the best of my knowledge.
Signature
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Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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