Permanent Makeup Treatment Form

Name*

First NameLast Name

E-mail Address*

Mobile Phone Number*

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Occupation

Date of Birth*

Please read these statements carefully Permanent cosmetics are a form of tattooing. - Re touch procedures may be required. - A healing period of 4 to 6 weeks is required before any touch-up procedure can be performed. - On rare occasions the pigment may migrate under the skin. - Application of permanent cosmetics can be uncomfortable. - The pigments will fade. - Immediately after the procedure, the pigment can be 30 to 50% darker than the desired result. - There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare. - A negative allergy test result will not guarantee that you will not have an allergic reaction. - Infections can occur if aftercare is not followed. - Allergic reactions to anesthetics can occur. - There may be swelling and redness following the procedure. - You may experience minor bleeding. - If you have a MRI scan within 3 months your permanent cosmetics procedure we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.*

I have read and understand the above statement

Signature

Close up front view of both brows

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Close up of right brow

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Close up of left brow

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Full facial to show the shape of your face

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How do you classify your eyebrows?*

ThinNormal, SparseThickOther

Please select the option the best describes the microblading treatment requested*

MicrobladeMicroblade & Shade

Provide a full picture of area to be treated

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What is your skin type?

DryDry-NormalOilyOther

How do you classify your lips?

ThinPlumpIn-betweenOther

Please list all the medication taken within the last 6 months

Have you taken any of the following in the last 48 hours?*

Rows	Yes	No
Aspirin
Ibuprofen
Coumandin
Alcohol

If 'yes' or 'another allergy' please provide additional information below

Do you have any of the following conditions?*

If 'yes' or 'another allergy' please provide additional information below.

Have you received chemotherapy or radiation treatment in the last year?*

YesNo

Are you currently experience any of the following conditions?:

Abnormal Heart Condition
Mitral Valve Prolapse
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Palpitations
Hepatitis
Cataracts
Blurred Vision
Dry Eyes
Eye Infection present
Alopecia
Recent Hair Loss
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Gore-Tex Implants/Silicone Injections
Fat Transfer Injections
Botox Injections
Collagen Injections
Hypertrophic Scars
Keloid Scars
Scar Easily
Healing Problems
Bruise or Bleed Easily
Sensitivity to Cosmetics
Use of Sun bed
Acutance within 6 months
Cortisone within 6 months
Chemical or laser peel within 6 months
Retin A within 6 months
AHA preparations within last 2 weeks

*

YesNoCondition Not Listed

If 'yes' or 'another condition' please provide additional information below.

I hereby authorize Kynnée Golder (permanent makeup technician) of Gold Standard Aesthtx to perform the permanent makeup treatment that I, the client, requested upon myself. If any unforeseen condition arises in the course of this procedure(s). I further request and authorize the technician to do what they deem advisable and necessary in the circumstances.*

YesNo

I accept responsibility for determining the color, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation.*

YesNo

I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I am aware of an allergic response to pigment is rare and accept all responsibility if an allergic response occurs.*

YesNo

I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-3 years. As well as being aware that when color has faded the pigment will stay in skin indefinitely and may leave a light residue of color.*

YesNo

I accept that the highest standards of hygiene are met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit.*

YesNo

I accept that dyes, inks, and pigments are not approved by the Food and Drug Administration (FDA) and the health effects are not known.*

YesNo

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 this is why I need to return for a retouch procedure that is not included in 1st procedure price.*

YesNo

I understand that a retouch procedure will be performed 1-3 months after the initial procedure and after a 3-month period I will be charged an additional fee for any further work as an initial visit.*

YesNo

The result of the procedure is determined by the following: - Medication - Skin Characteristics - dry, oily, sun-damaged and thickness - Natural skin undertones - Alcohol intake and smoking - Post procedure care treatment*

YesNo

Upon completion of the procedure there may be swelling and redness of the skin, which will subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately with moderate adjustments per Post-Procedure instructions (See specific post-procedure instructions for details.) You can however, be assured the procedure, even after only one treatment, looks acceptable and you should feel comfortable appearing in public without additional makeup on the affected area.*

YesNo

I have been advised that the true color will be seen 1 month after each procedure, and that the pigment may vary in color according to skin tones, skin type, age and skin conditions. I understand that some skins except pigment more readily than others and no guarantee to an exact effect or color can be given.*

YesNo

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, pregnant or breastfeeding.*

YesNo

I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. I understand infections and possible scarring can occur if I do not adhere to the said instructions.*

YesNo

Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by Kynnée Golder aka @gs.aesthtx or Gold Standard Aesthtx (microblading technician and business)*

I have read and understand the above information

For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the microblading procedure(s).*

I have read and understand the above information

Allergic Reaction– Allergic reaction can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptom associated with allergy. Numbness - We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is totally numb while others say they experience some discomfort. Procedure – For all procedures a cream or gel topical anesthetic is used. These products are perfectly safe, and can be purchased over the counter from any chemist. The anesthetic is placed over the treatment area for between twenty to thirty minutes then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between one and four days. You should always follow your post procedure instructions.*

I have read and understand the above information

Skin Type

Pigment Colour

Consultation Date:

Treatment Date:

Top-Up Date:

Location

Treatment Price

Top Up Price

Rows	Date Completed
Skin patch test
Pre instructions
After Care instructions
Before photos
After photos

Welcome Future Gold Standard Doll !

Permanent Makeup Area Information

Microblading/Blade+Shade Section

Scar Pigmentation and Lips Section

Medical Information

General Consent & Procedure Permit

Topical Anesthetic Form

Authorized Use Only