Clone of Eyebrow Cosmetic Tattoo Consent Form

1
Full Name* This field is required.
First Name
Last Name
2
Your Suburb and Post Code* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number* This field is required.
4
E-mail* This field is required.
example@example.com
5
Date of birth* This field is required.
DD/MM/YYYY
6
How did you hear about us?* This field is required.
Google
Social media
Word of mouth
Passing by
Others (Please specify...)
7
How did you hear about us? Others (Please specify...)
8
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)
Autoimmune disorder
Forehead / Brow / Face Lift
Chemical Peel
Hormonal imbalance
Cancer / Chemotherapy / Radiation
Accutane or acne treatment
Tumors / Growth / Cysts
Allergic reaction to any medications such as Epinephrine; Benzyl Alcohol; Carbopol; Lecithin; Propylene Glycol; Vitamin E Acetate
Using RetinA; Glycolic Acid; or Alpha Hydroxyl in your skin care routine
High blood pressure
Heart desease
Allergic reaction to anasthesia such as Lidocaine, Tetracaine, Dermacaine
Other
9
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 eyebrow tattoo appointment. If you have questions, please don‘t hesitate to ask. Eyebrow Microblading (or Feather Brow Tattoo) is a semi permanent cosmetic tattoo procedure where we create very natural hair stroke look to blend in with your natural hair brows. Ombre brows, also known as Powdered Brows, are a semi-permanent eyebrow styling technique that creates a soft shaded brow pencil look. It gives great brow definition & depth. Combination brows are a combination between Microblading and Powder brows. The tattoo colour is so lightly deposited under the skin so that the hair stroked look defines and real like a real hair. But this means it takes at least 2 sessions to get them looking perfect. Although eyebrow tattoo is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure. This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. 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 eyebrow tattoo service today
YESNO
10
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
11
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 tattoo 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
12
Care and maintenance* This field is required.WITHIN THE FIRST 2 WEEKS: 1. Do not wet your tattooed area for 2 weeks. Water will dilute the colour and your brows/eyeliner will end up being too light. Dirty water might also cause an infection 2. Do not cleanse or apply moisturisers over the tattooed area 3. Do not exercise for 2 weeks. After 2 weeks – when exercising, wear a sweatband to avoid sweat on tattooed area 4. Apply Aftercare cream onto tattooed area twice a day, morning and night. and before shower or before work out. Apply the product, leave it on for five to ten minutes (or while in shower), then with a tissue or dry cotton wipe gently across each brow once to get off the excess goo, then dab each brow till it is dry, after a couple minutes dab again to ensure that nothing is left on the brow. However, starting on day three when scab starts to appear, do not wipe - only dab till dry, you must be gentle, do not pull off the scabs prematurely. Your tattooed area should remain dry all day and all night. Following this procedure will ensure the formation of thin scabs thus more color retention. 5. The tatooed area may start flaking after a few days and get itchy. Do not force the flaking off (touch, rub, pick, or scratch), as this will pull the colour out and you will be left with more gaps 6. You may wear face make up straight after getting your cosmetic tattoo done, but do NOT apply make up over the top of the tattooed area for 2 weeks. Make up on top of the tattoo may change the pigment colour 7. For brow microblading, during the first 2 weeks, some hair strokes tattoo will stay and some will go, depending on different skin types. It is normal to see some gaps. You can not judge your brows until the end of the 6th weeks. WITHIN THE FIRST 4 WEEKS: Refrain from swimming in salt water or chlorinated pools, saunas, hot yoga, steam rooms WITHIN THE FIRST 6 MONTHS: 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 brows even after they are healed, because these products will change the color of pigment. 2. Exposing treated area to direct UV light (tanning bed or sunlight). After 30 days, use sunscreen to avoid fading from the sun CONFIRMATION I understand the result varies for everyone and overall skin conditions, and after care will ultimately affect the retention of 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
13
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 eyebrow microblading / 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
14
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
15
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
16
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
17
Unfortunately, it is strongly not reccomended to have cosmetic tattoo procedure done when you are pregnant or breatfeeding
18
You have to agree to our terms and conditions before services can be provided to you
Should be Empty: