• PERMANENT MAKEUP CONSENT FORM

    Please Fill Out Prior To Appointment
  • Client Details
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    Pick a Date
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    Pick a Date
  • Occupation

  • How Did You Hear About The Shaped Look?_______________________________________________________________
    I Reward For Referrals! If Referred, By Whom?__________________________________________

  • If Yes, Please Explain
    Eyebrows? Eyeliner? Scalp Micropigmentation? When?_________________________________________________________________________________________

  • Medical History Inquiry
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  • Contact in case of Emergency
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  • Contraindications For Procedure:

    1. Pregnant/Nursing

    2. Chemotherapy/Radiation Treatments (Currently Receiving)

    3. Sick with Cold/Flu/Fever/Coronavirus

    4. Active Herpes On The Face

    5. Eyelash Extensions & Contact Lenses Must Be Removed For Eyeliner

      

    Require Waiting Periods:

    1. Lasik/Cataract Surgery (Eyeliner Only-1 Month Prior & 3 Months Post-Op)

    2. Latisse (Eyeliner Only-2 Weeks)

    3. Botox (2 Weeks)

    4. Fillers (2 Weeks)

    5. Accutane (1 Year)

    6. Suntanned Skin (1 Month)

    7. Retinols/Glycolic Acid/Vitamin C Peels (1 Month)

    8. Shingles Shot (1 Month)

    9. Laser Treatment (8 Weeks)

    10. Coronavirus Vaccine (2 Weeks)

     

  • INFORMED CONSENT I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and I consent to receiving Permanent Makeup with Deanna, at The Shaped Look. I do not have any health conditions or issues that will prevent me from having the procedure. I acknowledge & have read the Pre-, During, & Post-, Procedure on The Shaped Look website and I agree to strictly adhere to such instructions. I understand that the process used to apply color is not a one-step process & requires subsequent visits to achieve desired results. I understand that with time pigment can & will fade & change color according to metabolism, skin type, medications, age, smoking, alcohol, skin exposure, Retin-A & Glycolic Acids. I acknowledge that no guarantees will be made concerning the results of this procedure. I understand that this is a tattooing process, therefore not an exact science, but an art. I understand the nature of the procedure & that adverse affects may occur such as redness, swelling, & tenderness. I accept responsibility for determining shape, color, & position of the pigment that will be applied. I understand that from 48 hours prior, during, & after the procedure there are no refunds. I give consent to photograph the treated area & this photograph may be used by The Shaped Look, on my portfolio, social media, & website for advertising purposes. I understand that a 2nd appointment (Perfection Visit), will need to be performed 6-8 weeks from initial visit. If not performed in this time frame there will be additional fees. I can have a patch test to identify any allergic reaction to any medicine or anesthetics at a Consultation appointment. Should I waive for the test, I release the Deanna, from The Shaped Look, from liability if I develop an allergic reaction to any of the procedure. 

    I certify that the information in the above questionaire is accurate.

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