Permanent Makeup Consent Form Logo
  • 3141 E Broad St Suite 303 Room 114, Mansfield, TX 76063
    (682) 213-0798
    lealux.glossgenius.com

  • Permanent Makeup Consent Form

  • Client Details

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  • Skin Conditions

    Do you have any of the following skin conditions? They may determine that you are not suitable for permanent makeup.
  • Medical Conditions

    Do you have any of the following medical conditions? They may determine that you are not suitable for permanent makeup.
  • Pre Procedure Advice

    • Permanent makeup procedure normally requires multiple treatment sessions. For best results clients will be required to return for at least one retouch appointment. This will take place 4 -6 weeks after the initial procedure. Those with oily skin may require an additional touch up. Please be aware that color intensity will be significantly darker and sharper immediately and a few days after the initial procedure but the color will reduce by 30-50%.
    • Although numbing cream is used during the procedure sensitivity or discomfort may still be felt. Skin may be red and/or swollen after the procedure.
    • Do not drink coffee or anything with caffeine the day of procedure.
    • Do not drink alcohol 24 hours prior to the treatment.
    • Do not work out 24 hours before procedure.
    • Do not shape or wax your brows before the procedure. Your technician will shape brows during the procedure.
    • Avoid sun and tanning one week prior.
    • Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure.
    • Chemical and laser peels should be avoided no less than 6 weeks prior to procedure.
    • Do not take Aspirin, Ibuprofen, Vitamin E, Fish oil, Niacin 24 hours before.
    • You must be off Retin-A or Retinols for 60 days prior to your appointment and avoid using on or around the area for 30 days after the appointment. Continued use will fade pigment prematurely.
    • You have to be off Accutane for 1 year.
    • If you have any pre-existing medical conditions, please consult your physician before making an appointment.
  • Topical Anesthetic Advice

  • Post Procedure Advice

    Please follow this regimen to speed up recovery and prevent complications such as infection.
  • Absorb (Day of)

    • After the procedure, gently blot the area with a clean tissue to absorb excess lymph fluid.
    • Do this every 5 minutes until the oozing has stopped.
    • Removing this fluid prevents hardening of the lymphatic fluids.​

    Wash (Days 1-7)

    • Wash daily to remove bacteria, build up of product and oils, and dead skin. (Don't worry, this does not remove the pigment.)
    • Gently wash the area each morning and night with water and gentle soap or an unscented cleanser like Dial Soap, Cetaphil, or baby shampoo.  With a very light touch, use your fingertips to gently cleanse the area.
    • Rub the area in a smooth motion for 10 seconds and rinse with water ensuring that all soap is rinsed away.
    • To dry, gently pat with a clean tissue. DO NOT use any cleansing products containing acids (glycolic, lactic, or AHA), or exfoliants.

    Moisturize and Hydrate (Days 1-7)

    • Apply a tiny, rice grain amount of provided ointment 3 times a day with a cotton swab and spread it across the treated area.
    • Be sure not to over-apply, as this will suffocate your skin and delay healing. The ointment should be barely noticeable on the skin.
    • NEVER put the ointment on a wet or damp tattoo.

    Important Reminders

    • Use a fresh pillowcase while you sleep.
    • Let any scabbing or dry skin naturally exfoliate away. Picking can cause scarring or loss of color.
    • No facials, botox, chemical treatments or microdermabrasion for 4 weeks.
    • Avoid hot, sweaty exercise for one week.
    • Avoid direct sun exposure or tanning for 4 weeks after the procedure.  Wear a hat when outdoors.
    • Avoid long, hot showers for the first 10 days.
    • Avoid sleeping on your face for the first 10 days.
    • Avoid face-down swimming, lakes, and hot tubs for the first 10 days.
    • Avoid topical makeup and sunscreen on the area.
    • DO NOT rub, pick, or scratch the treated area.​

    Important Instructions for Showering

    • Limit your showers to 5 minutes so that you do not create too much steam. Keep your face/procedure area out of the water while you wash your body, then, at the end of your shower, wash your hair.
    • Your face should only be getting wet only at the end of the shower.
    • Avoid excessive rinsing and hot water on the treated area.
    • Allergic reactions 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 show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.
    • Numbness – We cannot accept responsibility if the area to be treated does not respond to the numbing cream. Each individual is different according to skin type. Some clients report the area to be completely numb, while others may experience some discomfort.
    • Procedure – For permanent makeup, a numbing cream/gel is used. The products are formulated to be perfectly safe and can be purchased over the counter from any pharmacy. The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness/swelling that can last 1-4 days. You should always follow your post procedure advice and after care for the best results.
  • Consent

    Please check each box to show your understanding and agreement.
  • Signature

    This agreement will remain in effect for this procedure and all future permanent makeup procedures. I will alert the practitioner if there are any future changes to my medical history. By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.
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