CLIENT INTAKE FORM

NAME

This form will provide the necessary information to make an informed decision of whether or not to undergo a semi-permanent makeup application. Please do not hesitate to ask any questions.

Please review the following disclosures and initial each to verify you have received and understand each.

I have been advised that the pigment is permanent but will fade over time and that touch ups may be needed.

I have been quoted for the cost of the procedure and informed of the touch-up price. I understand that the initial touch-up is to be performed within 60 days in order to be booked at the touch-up rate. If I book anytime after that, I may be subjected to pay full price for the service requested.

I understand that anesthetics have varied effectiveness on each person and that discomfort of pain may persist even after a topical anesthetic has been applied.

I understand that swelling, redness, and bruising may occur from this procedure.

I understand the risks associated with the procedure(s) and that there may be complications such as infection, poor color retention, and hyper pigmentation.

I understand that I will be provided aftercare instructions, which I will follow to the best of my ability. If any questions or concerns arise, I will notify my cosmetic professional.

I accept the responsibility to decide and explain my desired colors, shapes, and for any procedures performed as agreed upon during consultation.

I understand that products containing Retin-A, Alpha Hydroxy, and Glycolic Acids are not to be used on the treated areas because they may alter the color or cause it to exfoliate prematurely.

I will tell any skincare professionals or medical personnel about my permanent makeup procedure(s), especially if I am to receive an MRI. I understand that this is because the pigment used may contain compounds that require a magnet.

I understand that exposure to the sun, tanning beds, pools, some skin care products, sweat, and medications can affect my permanent makeup.

I acknowledge that faces are not necessarily symmetrical and that while every effort is made to avoid asymmetry, adjustments may be required during the touch-up session to correct any un-evenness.

I understand that color saturation is not guaranteed and may be negatively affected by hidden scar tissue. I also acknowledge that pigment color may change or fade over time due to circumstances beyond my cosmetic professional’s control. I have been informed that some reasons for this include poor healing, improper aftercare, infection, bleeding and other causes. I understand that the touch-up sessions is meant to correct any fading, unforeseen changes, or uneven appearance.

I understand that infection is rare, but may occur and is serious. I acknowledge that keeping the treated areas clean is the best way to prevent infection. I will refer to and follow the provided aftercare instructions to be as proactive as possible in preventing infection.

I understand that I may have an allergic reaction to numbing agents or pigments used. I understand that even if a patch test is performed, it does not guarantee against an allergic reaction.

DISCOMFORT/PAIN: There is associated pain and discomfort that may persist even after topical anesthetic as been applied. Effectiveness of anesthetics and pain tolerance may very depending on each individual.

INFECTION: Infection is rare, but may occur and is serious. I acknowledge that I am to keep the treated areas clean. I will refer to and follow the provided aftercare instructions to be as proactive as possible in preventing infection.

APPEARANCE: Fading, patchiness, unevenness, and lack of retention may occur. Various factors contribute to these complications such as poor healing, improper aftercare, infection, bleeding, and other causes. Other products and exposures may also alter the final result.

SWELLING/BRUISING: Some individuals may bruise or swell following the procedure.

ASYMMETRY: Faces are not necessarily symmetrical and while every effort will be made to avoid asymmetry, adjustments may be required during the touch-up session to correct any uneveness.

ALLERGIC REACTIONS: Some individuals may have an allergic reaction to numbing agents or pigments used. A patch test may help avoid adverse reactions but cannot guarantee against them. It is the client's responsibility to inform their cosmetic professional of any known allergic reactions or sensitivities.

MRI: Clients are responsible for informing medical professionals about any semi-permanent makeup procedures received, especially if they are to receive an MRI. This is because the pigment used may contain compounds that require a magnet.

Signature

Date

Form

CLIENT PROFILE AND HISTORY

EMERGENCY CONTACT INFO

MEDICAL/SKIN HISTORY

PREVIOUS TREATMENTS/PROCEDURES

CONSENT AND RELEASE AGREEMENT

PLEASE READ AND INITIAL ALL LINES

Risk Acknowledgement

Photo & Video Release Consent