CLIENT INTAKE/CONSENT

APPOINTMENT DATE

Date

APPOINTMENT TIME

NAME

AGE

Address

Street, City

Street Address Line 2

Province

Postal code

Phone number

Email

Have you ever had a permanent makeup procedure before?

What would you like to improve/change about the area? (Consider shape, colour, density & thickness)

Do you have moles/raised areas in or around the treatment area?

Have you ever used an acne/scar medication? If yes, when/ where and which drug?

Have you used any of the following, within the last 6 months?: Retinal, Cortisone or Accutane if Yes where ?

NANO BROW - LIP BLISH - EYELINER QUESTIONS Have you had either a Chemical or Laser peel within the last 6 months?

Have you used AHA Preparations within the last 2 weeks? In the aria being treated today ?

NANO BROW QUESTION-Date of last eyelash/brow tint?

Have you or have you ever had any of the following?: Collagen Injections, Botox Injections, Sensitivity to Cosmetics Collagen Injections, Prone to allergies, Light Sensitivity, Gore-Tex Implants, Silicone Injections or Fat Transfer Injections in the aria that will be treated today ?

Do you have diabetes or any other autoimmune diseases?

Are you currently under the care of a physician and/or take any medication that thins the blood?

Have you ever had a Cold Sores? (herpes simplex)

Do you bruise or bleed easily?

List all medications you are taking currently (including over the counter drugs, vitamins etc.)

Do you have any of the following conditions?

Headaches or migraines, Vertigo or dizziness, ringing in ears, hearing loss, vision issues or loss?

Asthma, shortness of breath, Chronic cough, Bronchitis?

Arthritis, Osteoporosis, Tendonitis, Bursitis, or Jaw pain? (TMJ)

Herpes, Lyme disease, Infectious skin conditions?

High blood pressure, Low blood pressure, Heart attack, Stroke, Heart disease?

PMU EYELINER - LASH LINE QUESTION , Eye Infections, Refractive Errors, Dry Eye, Retinopathy, Glaucoma?

Cancer, Diabetes, Chronic fatigue, Unexplained Weight loss, Fibromyalgia?

HIV/AIDS?

Any other conditions?

If you suffer with any of the following it is important to notify us so we can take the necessary precautions to ensure your health isn't at risk.
Tree Nuts, Sunscreen, Pollen, Latex, Fruits, Shellfish and/or Lidocaine / Tetracine / Epinephrine ?

If yes. please specify

Are you pregnant or breastfeeding? Are you on hormone-replacement therapy? Are you on any Birth Control?

If yes. please explain

Is there anything else that should be known before starting your treatment?

I have read the above information and have given an accurate account to all questions. If I have any concerns I will address these with my esthetician before the service. I understand that the services offered are not a substitute for medical care and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information here is to aid the therapist in giving better service and is completely confidential.

Client Name (Printed)

Client Signature

Date

Therapist Name

Therapist Signature

Date

Please review the following information, which refers to your desire or approval to get permanent makeup procedures done on yourself. If you wish to have a permanent makeup procedure done. you must complete this consent form. The Client has been given a copy of this Agreement prior to the permanent makeup procedures being performed. I have been given the opportunity to attain reasonable understanding of this Agreement; Including the opportunity to ask questions, either by written, verbal or manual communication, prior to the signing of this document.

No warranty or guarantee has been made to me as a result of this permanent makeup/camouflage/correction procedure, and that the final result cannot be guaranteed. There may be risks and hazards related to the performance of this procedure planned for me.

I realize that there is potential for discomfort during the procedure and during the healing process.

There is a possibility of bleeding, swelling and allergic reactions to the dye. Tattooing is considered permanent, however it may fade with time. A tattoo can only be removed with a surgical procedure. Any effective removal may leave permanent scarring or disfigurement. Misplacement of the dye can occur, under rare circumstances, requiring excision of the misplaced dye. In rare cases there may be permanent loss of eyelashes.

I have been given the opportunity to ask questions about the procedure, the risks, and the hazards involved.

I believe that I have sufficient information to give this informed consent. The technician will not, under any circumstance, perform any permanent makeup procedures on me if I am known to have any allergies. As a Client, you have a responsibility to inform the technician working on you, of all possible concerns.

I understand that I must inform my technician of all medications being taken by me, even though I have written it on the client Intake Form. For example. pain control medication such as aspirin may cause the blood to thin and excessive bleeding may occur.

I understand that it is my responsibility to advise the technician of any concerns I may have before they begin the procedure. even though I may have written it down on the form.

I understand that the demonstrating technician may not be from the local area. if I would like to have any touch ups done by this technician, I may need to go where he/she is generally located.

During today's procedure, we may use epinephrine, lidocaine, or tetracaine. Since the treatment area involves the eyes, there is a chance that some product could come into contact with them. If you experience any stinging sensation, please inform your technician immediately.

Please note that it is your responsibility to either wait before driving home or arrange for someone to pick you up, as there is a potential side effect of blurry vision.

I am free from drug and alcohol use or any other substances.

STATEMENT OF ACKNOWLEDGEMENT: I have read and fully understand the questions, terms and disclosure conditions of this consent form. This consent form was completed by me, all entries and information in it are true and completed to the best of my knowledge.

Client Name (Printed)

Client Signature

Date

Technician Name

Technician Signature

Date

CLIENT INTAKE FORM

GENERAL INFORMATION:

HEALTH INFORMATION:

Do you have any of the following conditions?

CLIENT CONSENT