Permanent Makeup Consent Form
Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you over the age of 18?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
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Skin Contraindications
Ingrown hairs and open bumps on eyebrows/area of procedure
Injured/inflamed skin cannot be tattooed.
Eczema or Psoriasis
(Constant flaking/itching/irritation/shedding of skin).
Dermatitis
(Constant flaking/itching/irritation/shedding of skin).
Rosacea
(Chronic acne-like skin indicated by redness). Skin bleeds easy and will not retain pigment well.
Moles/raised areas on/around area of procedure
Anything raised will not retain color.
Deep wrinkles in the eyebrow area
Hair-strokes will not lay properly in the creases, giving the eyebrows an uneven look.
Hair transplant for your eyebrows
Pigment may not take in the scar tissue where the plugs were placed.
Accutane (acne medication) within the last 6 months
Skin composition is altered and will not heal well. Must wait 6 months before applying permanent makeup
Retinol or Vitamin A user
Skin composition is altered. Must discontinue use 1 months prior to procedure.
Extremely thin skin
Transparent or translucent skin bleeds easily and cannot hold pigment due to its thinness.
Sunburnt skin
Skin is not normal color and is damaged.
Use of Latisse or any eyelash/eyebrow growth conditioner
Hair follicles are hypersensitive and will bleed easily. Use must discontinued for 2 months prior to any procedure.
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Medical Conditions
Pregnant or nursing
At risk and sensitive due to change in hormones
Hemophilia
High risk - cannot stop bleeding
Heart Conditions/Pacemaker/Defibrillator (No exceptions)
High risk and on blood-thinning medications
Bleeding disorders
Increased bleeding which prevents pigment deposit
Thyroid condition and taking medication for this condition
Hypo, Hyper-thyroidism, Graves Disease, Hashimoto's, etc. Results in thicker skin.
Auto Immune Disorder such as LUPUS or Frontal Fibrosing Alopecia(MS, RA, Lupus or the like).
Due to the medicines to treat these diseases, the skin is altered and pigment will not retain. Also, the facial skin is not healthy and/or is bumpy, and the color will not heal evenly.
Trichotillomania (Compulsive pulling of body hair)
Due to constant pulling, scar tissue is prominent and pigment will not heal evenly/properly.
If you are using any of the following medications you may have excessive bleeding and the pigment MAY NOT retain:
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Client Health History
Do you have a history of skin sensitivities?
*
Yes
No
Do you have any known allergic reactions or sensitivities to any topical or local anesthetics?
*
Yes
No
Are you allergic to lidocaine or any other numbing agents?
*
Yes
No
Do you have any allergies (i.e. Polysporin, Bacitracin, Neosporin, Latex, etc.)?
*
Yes
No
Are you allergic or sensitive to any metals?
*
Yes
No
Do you have any heart conditions or high blood pressure?
*
Yes
No
Do you have or do you think it is possible that you have any blood borne communicable disease such as HIV or Hepatitis?
Yes
No
Have you ever had a Herpes Simplex Type 1 infection?
Yes
No
Have you ever had cold sores or fever blisters?
*
Yes
No
Do you have diabetes, currently on any form of immunosuppressant therapy or any condition that may delay healing?
*
Yes
No
Do you have issues healing?
*
Yes
No
Are you prone to keloid scarring, hypertrophic scarring or any other form of excessive scarring condition?
*
Yes
No
Do you have eczema, rosacea, dermatitis or alopecia?
*
Yes
No
Do you routinely use Retin-A, glycolic or other exfoliating products?
*
Yes
No
Do you have any known personal history or family history of Methemoglobinemia?
*
Yes
No
Have you had alcohol or caffeine in the last 24 hours?
Yes
No
Do you wear contact lenses?
*
Yes
No
Do you consume aspirin daily?
*
Yes
No
Do you have a bleeding disorder or take blood thinners?
*
Yes
No
Do you use tobacco?
Yes
No
Do you have any autoimmune disorders?
*
Yes
No
Have you had any form of cosmetic or surgical procedure, Radiotherapy or Chemotherapy at any time within the last 6 months? (botox, injections, laser therapies, facelifts, etc.)
*
Yes
No
Are you now, or have you ever been on the acne treatment Accutane?
*
Yes
No
Have you had permanent makeup before?
*
Yes
No
If you have permanent cosmetics or tattoos, did you have any problems with healing after they were applied?
*
Yes
No
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Photo Consent
For the purpose of documentation, I consent to the taking of before and after photographs.Please note, these will NOT be used for marketing of any kind. Your artist requires you to consent to photographs for her professional and confidential customer files.
*
Yes
No
I consent to the use of my photos for the purposes of marketing.My pictures my appear in print or online.
*
Yes
No
I hereby consent to Kaylee’s Esthetics taking photographs of the undersigned both before and after any procedures being undertaken by Kaylee’s Esthetics at the request of the undersigned. It is further acknowledged that the undersigned authorizes Kaylee’s Esthetics to use such photographs in compiling albums of its various clients for the purpose of showing potential clients the procedures completed.
Signature
Date
-
Month
-
Day
Year
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Consent to Procedure
I have received and reviewed this informed consent document for permanent makeup.
I am over 18 and I am not pregnant or nursing.
I agree to the use of such topical anesthesia considered necessary.
I understand that the color outcome may be slightly modified due to the undertone and health of the skin and results will vary depending on a variety of factors.
I understand that failure to follow aftercare instructions could result in less than satisfactory results.
I understand that permanent makeup will fade over time due to environmental and lifestyle factors.
The UNDERSIGNED acknowledges that Kaylee’s Esthetics has explained the nature of procedure, including the risks and dangers inherent there in. I HEREBY CONSENT to Kaylee’s Esthetics performing eyebrow microblading treatment and its procedures on me and in consideration of her doing so, I hereby release and forever discharge Kaylee’s Esthetics from all demands, damages, actions or causes of action arising out of the performances of the said treatment procedures, which I,can, shall or may have. No refund on any treatment. I accept the above colour, design, and payment terms in this contract.
Signature
Date
-
Month
-
Day
Year
Date
Submit
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