Clone of Eyeliner Cosmetic Tattoo Consent Form

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Phone Number* This field is required.
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example@example.com
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Date of birth* This field is required.
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How did you hear about us? Others (Please specify...)
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Please tick any of the following that applies to you:
Pregnant/Breastfeeding
Easily bruised
Diabetes
Alcoholism
Oily skin
Botox
Have had keloid
History of MRSA
Hepatitis A B C D
Taking blood thinners such as: Aspirin; Warfarin; Plavix (Clopidogrel)
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Using RetinA; Glycolic Acid; or Alpha Hydroxyl in your skin care routine
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Precautions and Considerations* This field is required.This form is designed to give information needed to make an informed choice of whether or not to undergo an eyeliner tattoo appointment. If you have questions, please don‘t hesitate to ask. Inner Eyeliner Tattoo is a very subtle tattoo application. It is done as a thin line that does not leave the lash area, and it also does not give you that eyeliner flick at the end. 3D Eyeliner Tattoo is a medium-width eyeliner tattoo application that is perfect for women who wear makeup every day and want a look that makes their eyes bold but still relatively natural. This tattoo can be done with a flick at the end (wing). Misty Eyeliner Tattoo is a a form of cosmetic tattooing which gives you that misty and smokey eyeshadow look. This tattoo can be done with a flick at the end (wing). The colour is so lightly deposited under the skin, and this means it may take at least 2 sessions to get them looking perfect. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are stickily adhered to. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed. Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 3 months to 1.5 years. I confirm that I have read the precautions and considerations mentioned above and would like to proceed with eyeliner tattoo service
YESNO
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Permission to use pictures* This field is required.I hereby grant my service provider the full right to take, publish and reproduce photographs of me, my face, my eyes and/or brows, both before and after the procedure, for any advertising, education, or other purposes whatsoever.
YESNO
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Waiver of liability* This field is required.I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur. There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others. Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now. I understand that some swelling and bruising may occur. Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Every effort will be made to avoid asymmetry, but out faces our not symmetrical so adjustments may be needed during the follow-up session to correct any unevenness. I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. I accept the responsibility to explain to you my desire for specific colors, shape, and position for any procedure done today. I acknowledge that the proposed procedures involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation. Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. I agree that if I experience any of these conditions with my eyelid that I will contact professional technician and my GP to seek for immediate attention. Even though my technician will use the proper techniques, the instruments, tapes, cleansers, wax, tint, henna, and other products use may irritate my skin. I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI. Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. I understand that tanning beds, pools, some skin care products and medications can affect my semi permanent makeup. I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 1-2 months. This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance. I further agree that I will not hold Mollylash or any of its employees responsible should there be any unfavourable result. I acknowledge and consent to the use of CCTV cameras with microphones in the reception area for the purposes of quality assurance and training. I understand that these recordings are used to enhance service quality and for staff training purposes. Please note that no refund will be given under any circumstances.
YESNO
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Care and maintenance* This field is required.EYELINER TATTOO WHAT TO EXPECT AFTER APPOINTMENT Day 0 : This can vary slightly puffy to swollen, heavy lids, light sensitive. It is advisable to sleep in elevated position to help reduce swelling Day 1: Eyes will be swollen and perhaps a bit crusty upon waking. The swelling will reduce after being in an upright position and from blinking and increased circulation to the area. Avoid heavy lifting, phsyical exertion, and crying. Day 2: Eyes will be less swoleen, but will feel tight. The lash area will feel sore if touched. Day 3-4: The top layer of the skin will begin to flake offf in little stitch looking lines, although some people do not notice the exfoliation, DO NOT PICK- You will pull piment out and end up with uneven color. Blinking helps eliminate the small pieces of pigment and epidermis that has detached. It is important to not pick at it or rub the eyes. Day 7-9: All shedding should be complete. You are safe to put your face back in the shower spray. During this time, the tattoo may appear to have vanished. This is a normal part of the healing process, and the pigment will re-emerge. Day 10: The pigment will be faded by 30-40%. Please wait the final three weeks to heal your skin completely and return for a 1-2 months touch up procedure. AFTERCARE INSTRUCTIONS 1. Ice packs protected with a cloth may be applied as necessary to reduce swelling. Sleeping slightly elevated helps alleviate swelling sometimes seen in the morning after facial procedures. 2. Wash your hands before touching any treated area. Cotton tipped applicators may be used to gently cleanse the eye area. Do not expose the area to dirty or unsanitary conditions. Wearing lasses outdoors is a good way to protect new eyeliner from dust, etc. 3. Some itching is normal. DO NOT PICK, PEEL, OR SCATCH the treated area or your color may heal unevenly and you risk scarring and infection. 4. No make up is to be applied for 72 hours (three days) after the procedure on tattoo area. After any eyeliner procedure, throw away your old mascara to avoid infection. Do not use eyelash curler for 2 weeks. 5. Do not expose your healing skin to direct shower spray, skin creams, ointments, or lotions other than what you have been instructed to use for at least 3 days following your procedure. 6. Do not expose your healing skin to diret sun, tanning beds, hot tubs, saunas, salt water, chlorinated pools, or extremely hot water for 2 weeks following your procedure. 7. During the first 2 weeks, some tattoo will stay and some will go, depending on different skin types. It is normal to see some gaps. You can not judge your eyeliner tatoo until the end of the 6th weeks. 8. You cannot donate blood for 6 months after getting a tattoo. This is a universal rule by the Red Cross AVOID: 1. Retin-A or any acids (glycolic, AHA, etc) on your eyeliner tattoo even after they are healed, because these products will change the color of the. pigment. 2. Exposing treated area to direct UV light (tanning bed or sunlight). Use good sunscreen daily, after tattooed area is completely healed. Sun exposure will fade your tattoo and may cause irritation even years later. CONFIRMATION I understand the result varies for everyone and overall skin conditions, and after care will ultimately affect the retention of eyeliner tattoo Aftercare instructions have been explained to me and a digital copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email you. I agree to follow the maintenance instruction provided to me by my technician, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk.
YESNO
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No Known Medical Conditions / Informed Consent* This field is required.I have read and completed the Client Consent Form in its entirety and in truth. I understand that I need to disclose any allergies that I may have to materials or equipment used in eyeliner tattoo service. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to instructions or these warnings. This Agreement will remain in effect for this procedure, and all future procedures.
YESNO
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Signature* This field is required.I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement.
I am over 18 years old
I am under 18 years old
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Signature of legal guardianI agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I am under 18 years of age and I have my parent or legal guardians consent to this agreement.
Clear
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SignatureI agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am at least 18 years of age and that I have the right to enter this agreement
Clear
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Unfortunately, it is strongly not reccomended to have eyebrow microblading procedure done when you are pregnant or breatfeeding
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You have to agree to our terms and conditions before services can be provided to you
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