SEMI PERMANENT MAKEUP

SEMI PERMANENT MAKEUP

CONSULTATION FORM
CLIENT INFORMATION:
Name*

FIRST NAMELAST NAME
DATE OF BIRTH*

DayMonthYear
Date
AGE*
ADDRESS*
CITY
COUNTY
POST CODE*
PHONE*

Area CodePhone Number
EMAIL
example@example.com
EMERGENCY CONTACT NAME
PHONE

Area CodePhone Number
HOW DID YOU HEAR ABOUT US?
MEDICAL HISTORY:
PLEASE CHECK ANY APPLICABLE BOXES AND PROVIDE ADDITIONAL DETAILS WHERE NECESSARY. DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
OTHER
IF TICKED YES TO ANY OF THE ABOVE PLEASE PROVIDE DETAILS:
HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY OF THE FOLLOWING?
YesNo
YesNo
YesNo
OTHER
IF TICKED YES TO ANY OF THE ABOVE PLEASE PROVIDE DETAILS:
WHAT MEDICATIONS/VITAMINS AND DOSAGE ARE YOU CURRENTLY TAKING? (PLEASE LIST)
SKIN CONDITIONS:
PLEASE CHECK ANY APPLICABLE BOXES AND PROVIDE ADDITIONAL DETAILS WHERE NECESSARY. DO YOU HAVE ANY OF THE FOLLOWING SKIN CONDITIONS?
Ingrown hairsMoles / raised areasDermatitisDeep wrinkles in eye/eyebrow areaRosaceaPsoriasisHair transplantNone of the above
IF TICKED YES TO ANY OF THE ABOVE PLEASE PROVIDE DETAILS:
DO YOU FORM THICK OR RAISED SCARS FROM CUTS OR BURNS?
YesNo
DO YOU GET HYPER-PIGMENTATION (DARKENING OF THE SKIN), HYPO-PIGMENTATION (LIGHTENING OF THE SKIN) OR MARKS AFTER PHYSICAL TRAUMA?
YesNo
HAVE YOU HAD ANY RECENT TANNING OR SUN EXPOSURE THAT CHANGED THE COLOR OF YOUR FACIAL SKIN?
YesNo
DO YOU HAVE ANY PIERCINGS IN THE TREATMENT AREA?
YesNo
LIST ANY TOPICAL MEDICATIONS, CLEANSERS, OR CREAMS YOU ARE CURRENTLY USING ON YOUR FACE:
HAVE YOU RECENTLY HAD TREATMENTS SUCH AS FACIALS, PEELS, MICRODERMABRASION, ETC. ON YOUR FACE? IF SO, PLEASE SPECIFY:
HAVE YOU HAD ANY PREVIOUS PERMANENT MAKEUP OR TATTOO PROCEDURES BEFORE? IF SO, PLEASE INDICATE WHEN:
YesNo
IF SO, PLEASE SPECIFY WHEN AND WHAT AREA:
YesNo
WHICH OF THE FOLLOWING DESCRIBES YOUR SKIN TYPE?
NormalDryOilyCombinationSun damaged
ARE YOU PREGNANT OR TRYING TO BECOME PREGNANT?
YesNo
ARE YOU BREASTFEEDING?
YesNo
WHAT ARE YOUR EXPECTATIONS AND GOALS FOR THE TREATMENT? WHAT WOULD YOU LIKE TO IMPROVE/CHANGE ABOUT THE AREA? CONSIDER SHAPE, COLOR, DENSITY, THICKNESS.*
ANY QUESTIONS OR CONCERNS ABOUT THE PROCEDURE?
I UNDERSTAND, HAVE READ AND COMPLETED THIS QUESTIONNAIRE TRUTHFULLY. I AGREE THAT THIS CONSTITUTES FULL DISCLOSURE, AND THAT IT SUPERSEDES ANY PREVIOUS VERBAL OR WRITTEN DISCLOSURES. I UNDERSTAND THAT WITHHOLDING INFORMATION OR PROVIDING MISINFORMATION MAY RESULT IN CONTRAINDICATIONS AND/OR IRRITATION TO THE SKIN FROM TREATMENT RECEIVED. THE TREATMENTS I RECEIVE HERE ARE VOLUNTARY AND I RELEASE THIS SKIN CARE PROFESSIONAL FROM LIABILITY AND ASSUME FULL RESPONSIBILITY THEREOF.
CLIENT NAME*
SIGNATURE*
DATE*

DayMonthYear
Date
TECHNICIAN
SIGNATURE
DATE

DayMonthYear
Date
HEREBY CONFIRM THAT I AM OF LEGAL AGE, BEING OVER 18 YEARS OLD, AND THAT I AM NOT UNDER THE INFLUENCE OF DRUGS OR ALCOHOL. I ALSO AFFIRM THAT I AM NOT PRESENTLY PREGNANT OR NURSING. I WILLINGLY PROVIDE MY CONSENT FOR THE MICRO-PIGMENTATION OR PERMANENT COSMETIC PROCEDURE THAT HAS BEEN DISCUSSED AND SPECIFIED.

I ALLOW MY THERAPIST PERMISSION TO USE PROFESSIONAL JUDGEMENT TO DETERMINE WHAT IS NECESSARY IN THE EVENT OF AN UNEXPECTED CONDITION THAT EMERGES DURING THE PROCESS. I ACKNOWLEDGE THAT, AS DECIDED UPON DURING THE CONSULTATION, I AM RESPONSIBLE FOR CHOOSING THE MICROBLADING PROCEDURE'S COLOUR, SHAPE, AND PLACEMENT. I UNDERSTAND AND AGREE THAT THE TREATMENT USES NON-TOXIC PIGMENTS, AND THAT THE DESIRED OUTCOME MAY FADE OVER A ONE TO THREE-YEAR PERIOD. PIGMENT ITSELF MAY REMAIN IN THE SKIN INDEFINITELY, EVEN AFTER THE COLOUR HAS FADED.

I HAVE BEEN INFORMED THAT THE HIGHEST STANDARDS OF HYGIENE ARE MET AND THAT STERILE, DISPOSABLE NEEDLES AND PIGMENT CONTAINERS ARE USED FOR EACH INDIVIDUAL CLIENT, PROCEDURE AND VISIT. I ACKNOWLEDGE AND REALISE THAT NO METHOD CAN GUARANTEE 100% SUCCESS THE FIRST TIME AROUND AND THAT EACH PROCEDURE MAY REQUIRE NUMEROUS PIGMENT APPLICATIONS TO ATTAIN DESIRED RESULTS. I UNDERSTAND THAT I HAVE TO RETURN FOR A 6/8 WEEK TOP UP PROCEDURE, IF THE TOP UP GOES OVER 8 WEEKS POST TREATMENT IT MAY NOT BE ABLE TO BE COMPLETED. IT IS MY RESPONSIBILITY TO BOOK THE TOP UP TREATMENT IN THE REQUIRED TIME FRAME, WITHOUT THIS, FINAL RESULTS MAY BE JEOPARDISED.

THE RESULT OF THE PROCEDURE CAN BE AFFECTED BY THE FOLLOWING: MEDICATION, SKIN CHARACTERISTICS (DRY, OILY, SUN-DAMAGED THICK OR THIN SKIN TYPE), PERSONAL PH BALANCE OF YOUR SKIN, ALCOHOL INTAKE AND SMOKING, POST PROCEDURE AFTER CARE.

FOLLOWING THE PROCEDURE, THERE MAY BE SOME SKIN REDNESS AND SWELLING, BUT THESE WILL GO AWAY IN ONE TO FOUR DAYS. THERE'S A CHANCE OF BRUISES SOMETIMES. AFTER THE TREATMENT, YOU CAN GO BACK TO YOUR REGULAR ACTIVITIES. HOWEVER, UNTIL THE SKIN HAS COMPLETELY HEALED, YOU SHOULD AVOID USING MAKEUP, PERSPIRING EXCESSIVELY, AND GOING OUTSIDE IN THE SUN. FURTHER INFORMATION CAN BE FOUND IN THE AFTERCARE INSTRUCTIONS. YOU WON'T NEED TO APPLY ANY MORE MAKEUP IN ORDER TO APPEAR IN PUBLIC AFTER THE TREATMENT AND DOING SO MAY AFFECT PIGMENT COLOUR AND RETENTION.

I HAVE BEEN ADVISED THAT THE TRUE COLOUR WILL BE SEEN 4/6 WEEKS AFTER EACH PROCEDURE, AND THAT THE PIGMENT MAY VARY ACCORDING TO SKIN TONES, SKIN TYPE, AGE AND SKIN CONDITION. I UNDERSTAND THAT SOME SKIN TYPES ACCEPT PIGMENT MORE READILY AND NO GUARANTEE ON EXACT COLOR CAN BE GIVEN.

TO MY KNOWLEDGE, I DO NOT HAVE ANY PHYSICAL, MENTAL OR MEDICAL IMPAIRMENT OR DISABILITY THAT MIGHT AFFECT MY WELL BEING AS A DIRECT OR INDIRECT RESULT OF MY DECISION TO HAVE THE PROCEDURE DONE AT THIS TIME.
YesNo
CLIENT NAME*
SIGNATURE*
DATE*

DayMonthYear
Date
PERMANENT MAKEUP CLIENT CONSENT:
I AGREE TO FOLLOW ALL PRE-PROCEDURE AND POST-PROCEDURE INSTRUCTIONS AS PROVIDED AND EXPLAINED TO ME BY THE TECHNICIAN. FAILURE TO DO SO MAY JEOPARDIZE MY CHANCES FOR A SUCCESSFUL PROCEDURE.

I CAN CONFIRM THAT I WILL RECEIVE A COPY OF AFTER CARE DETAILS.

I AM AWARE OF THE CAUSES, HAZARDS, POTENTIAL COMPLICATIONS, AND LONG-TERM EFFECTS OF PERMANENT SKIN PIGMENTATION. I UNDERSTAND THAT PERMANENT SKIN PIGMENTATION IS A COSMETIC OPERATION WITH KNOWN AND UNKNOWN RISKS AND SIDE EFFECTS, SUCH AS INFECTION, UNEVEN COLOUR, AND PIGMENT SPREADING, FANNING, OR FADING. I AM AWARE THAT MY SKIN'S TONE AND COLOUR MAY SLIGHTLY ALTER THE PIGMENT'S ACTUAL COLOUR.

I FULLY UNDERSTAND THIS IS A TATTOO PROCESS AND THEREFORE NOT AN EXACT SCIENCE BUT AN ART. I REQUEST THE SEMI- PERMANENT SKIN PIGMENTATION PROCEDURE(S) AND ACCEPT THE PERMANENCE OF THIS PROCEDURE AS WELL AS THE POSSIBLE COMPLICATIONS AND CONSEQUENCES OF THE SAID PROCEDURE.

AN ALLERGIC REACTION TO THE NUMBING AGENT AND/OR PIGMENTS IS POSSIBLE. ALTHOUGH A PATCH TEST IS AVAILABLE, IT DOES NOT GUARANTEE THAT A CUSTOMER WON'T EXPERIENCE ANY ALLERGIC REACTION. I RELEASE THE TECHNICIAN FROM LIABILITY IN THE EVENT THAT I EXPERIENCE AN ALLERGIC REACTION TO THE PIGMENT, IF WAIVED. I AGREE TO THE PATCH TEST OR I WAIVE THE PATCH TEST, BUT NOT BOTH AT FIRST.

I UNDERSTAND THAT IF I HAVE ANY SKIN TREATMENTS, INJECTABLES, LASER HAIR REMOVAL, PLASTIC SURGERY OR OTHER SKIN ALTERING PROCEDURES, IT MAY RESULT IN ADVERSE CHANGES TO MY MICROBLADING PROCEDURE. I ACKNOWLEDGE SOME OF THESE POTENTIAL ADVERSE CHANGES MAY NOT BE CORRECTABLE.

I ATTEST THAT I HAVE READ THE PRECEDING PARAGRAPHS, INITIALLED THEM, AND UNDERSTOOD THE CONSENT AND PROCEDURE ALLOWS. I FULLY ACKNOWLEDGE THAT I MADE THE DECISION TO GET THIS SEMI-PERMANENT COSMETIC PIGMENTATION DONE.

I ALLOW ABIGAEL EVA AESTHETICS TO TAKE AND USE PHOTOS OF MY PRE & POST TREATMENT, THESE CAN BE USED FOR ABIGAEL EVA AESTHETICS ONLY AND ABIGAEL EVA AESTHETICS WILL OWN THE PHOTOS.

MY SIGNATURE ACKNOWLEDGES THAT I HAVE READ AND AGREE THAT I WILL ADHERE TO ALL OF THE AFOREMENTIONED STATEMENTS THAT I HAVE INITIALED.
I agree to the deposit and cancellation terms on Abigael Eva Aesthetics & Beauty’s booking system. Deposits are non-refundable. I understand that less than 72 hrs notice will incur a cancellation fee of the deposit amount. If more than 72 hours notice is given my deposit can be transferred to another date, I have the option to do this once for my booking. Abigael Eva Aesthetics reserves the right to cancel/change the booking due to illness, injury or extenuating circumstances and best efforts will be made to find the next available appointment for my treatment; my deposit will be transferred to my chosen date in this event.
CLIENT NAME*
SIGNATURE*
DATE*

DayMonthYear
Date
TECHNICIAN
SIGNATURE
DATE

DayMonthYear
Date
THE FOLLOWING IS TO BE FILLED OUT AT THE END OF YOUR TREATMENT

SCROLL TO BOTTOM TO SUBMIT FORM

Rows	DD/MM/YY	Treatment	Pigment colour	Needle	Price	Aftercare received
Date:
Notes:
Any medical changes since last visit

Please rate your treatment today:
Signature

Rows	DD/MM/YY	Treatment	Pigment colour	Needle	Price	Aftercare received
Date:
Notes:
Any medical changes since last visit

Please rate your treatment today:
Signature

Rows	DD/MM/YY	Treatment	Pigment colour	Needle	Price	Aftercare received
Date:
Notes:
Any medical changes since last visit

Please rate your treatment today:
Signature
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SEMI PERMANENT MAKEUP

CLIENT INFORMATION:

MEDICAL HISTORY:

HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY OF THE FOLLOWING?

SKIN CONDITIONS:

DO YOU FORM THICK OR RAISED SCARS FROM CUTS OR BURNS?

DO YOU GET HYPER-PIGMENTATION (DARKENING OF THE SKIN), HYPO-PIGMENTATION (LIGHTENING OF THE SKIN) OR MARKS AFTER PHYSICAL TRAUMA?

HAVE YOU HAD ANY RECENT TANNING OR SUN EXPOSURE THAT CHANGED THE COLOR OF YOUR FACIAL SKIN?

DO YOU HAVE ANY PIERCINGS IN THE TREATMENT AREA?

HAVE YOU HAD ANY PREVIOUS PERMANENT MAKEUP OR TATTOO PROCEDURES BEFORE? IF SO, PLEASE INDICATE WHEN:

WHICH OF THE FOLLOWING DESCRIBES YOUR SKIN TYPE?

ARE YOU PREGNANT OR TRYING TO BECOME PREGNANT?

ARE YOU BREASTFEEDING?

PERMANENT MAKEUP CLIENT CONSENT:

THE FOLLOWING IS TO BE FILLED OUT AT THE END OF YOUR TREATMENT