PERMANENT MAKEUP

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Name* This field is required.
First Name
Last Name
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Date* This field is required.
Date
Month
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Date of Birth* This field is required.
Date
Month
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Gender
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Address
Street Address
Street Address Line 2
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Phone* This field is required.
Please enter a valid phone number.
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Email* This field is required.
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Emergency Contact* This field is required.
Please enter a valid phone number.
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How did you hear about us?
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Would you like to be added to our email list for news and exclusive offers?* This field is required.
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MEDICAL HISTORYDo you have or have you had any of the following conditions? If yes, please select them:
Autoimmune Disorder
Aids/HIV
Bleeding Disorder
Cancer
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Depression/Mood disorder
Diabetes
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History of MRSA
Hypertronic Scarring/Keloids
Kidney disease
Liver disease
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Psoriasis/Dermatitis
Radiation
Skin condition
Serious Heart Condition
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Any other condition
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Have you ever had an allergic reaction to latex?
Yes
No
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Have you ever had an allergic reaction to antibiotics?
Yes
No
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Do you have any other allergies?
Yes
No
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If "Yes", right down your known allergies.
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List any medications you take regularly, including vitamins, herbal supplements, aspirin:
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Have you taken any of the following in the last 2 days: Aspirin, Ibuprofen, Coumadin, Alcohol?
Yes
No
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If "Yes", please explain.
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Do you wear contact lenses?
Yes
No
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Do you often have eye irritation, itching or watery eyes?
Yes
No
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Have you had any permanent or semi-permanent makeup services done before?
Yes
No
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If yes, what kind of permanent makeup did you do?
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Have you ever had Blepharoplasty (eyelid surgery)
Yes
No
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If yes, when?
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Have you ever had Forehead / brow lift?
Yes
No
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If yes, when?
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Have you ever had Lasik eye surgery
Yes
No
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If yes, when?
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Have you had any facial or dermatology services in the last 30 days?
Yes
No
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Have you recently done a chemical peel?
Yes
No
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If yes, when?
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Are you currently wearing lash extensions?
Yes
No
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Do you have a tanned/sunburnt skin?
Yes
No
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Have you used Latisse or any eyelash/eyebrow growth conditioner within the last 2 months?
Yes
No
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Have you received Accutane (acne medication) within the last year?
Yes
No
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Have you received Botox, Lip fillers, Restylane, Juvederm or Collagen in the last 6 months?
Yes
No
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Have you used Retin-A, Renova, AHA, BHA, Retinoid or Retinol products in the last 3 months?
Yes
No
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I hereby consent to and authorize Rana Albasha to perform the following procedure: blanks .
Although every precaution will be take to ensure your safety and well being before, during, and after your microblading, please be aware of the following information and possible risks.
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Please initial each statement:
I am over the age of 18 and in sound mind, body, and health.
I understand that I will have permanent and/or semi-permanent cosmetic (referred to on this form as PMU/SPMU) makeup applied using the highest standards of hygiene and that sterile disposable needles and pigment containers are used for each individual client, procedure, and visit.
I understand and accept that permanent makeup is a process, often requiring multiple treatment visits to achieve desirable results and 100% success cannot be guaranteed.
I have been advised that the pigment result may vary according to skin tones, skin type, ethnicity, age, lifestyle, post-procedure care and general skin conditions. And I understand no guarantee on exact color results can be given.
I am aware that the true healed color will be visible 6-8 weeks after each procedure.
I accept the responsibility for determining and agreeing to the color, shape, and position of the PMU/SPMU procedure as agreed upon during the consultation.
I fully understand and accept that non-toxic pigments are used during the procedure and that the results will fade over time, however, some trace pigment may stay in the skin indefinitely.
I have been advised that annual touch-ups are encouraged to maintain the integrity of the color.
If an unforeseen condition arises in the course of the PMU/SPMU procedure, I authorize the technician to use his/her professional judgment in deciding what she feels is necessary under the given circumstances.
I can confirm that I have received before and aftercare instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.
If I wear contacts, I am aware that I must remove them prior to an eyeliner procedure.
I am aware that I must remove any false eyelashes prior to an Eyeliner/Lash Enhancement procedure. I am also aware that any lash enhancement serums or conditioners can affect the outcome of my Eyeliner/Lash Enhancement procedure.
I acknowledge that my skin is vulnerable to infection directly after a PMU/SPMU application, and I am to contact my primary physician if I see any signs of infection.
I understand that using cosmetics, excessive perspiration, and sun exposure should be limited until the skin has fully healed.
Allergic reactions are always a possibility. I understand that a patch test/allergy test does not guarantee that I will not have an allergic reaction and I release the technician from liability should I develop an allergic reaction to any of the topical preparations, pigments, dyes or the anesthesia used in the procedure.
I understand it’s impossible to list every potential risk and complication. I agree to have been informed of possible benefits, risks, and complications including but not limited to: redness or other discoloration, temporary bleeding, bruising, swelling, irritation, pain, fading or loss of pigment, and cold sores on lips.
I am aware that if I am to have an MRI after the procedure, I must tell the radiologist that I have iron oxide permanent cosmetics.
I understand that laser hair removal procedures may turn lip pigment dark or black.
I understand the positioning of my PMU/SPMU procedure can be affected if I elect to have cosmetic surgery, Botox, Restylane or other cosmetic or surgical procedures.
I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors that my technician has no control over. I understand that additional appointments after the initial and follow up appointments may be required.
I acknowledge that the procedure may result in a long lasting (many years) change to my appearance and that no representation has been made to me as to the ability to later change the results. I am aware that it can be costly to remove.
I understand tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown.
I consent to the taking of before and after photos for the purpose of record keeping & documentation required by the Technician's insurance company.
I further authorize that exceptional photographs or results may be used in advertising or promotional materials and I give permission for such usage.
I am not pregnant or nursing, do not have Hepatitis, HIV/AIDS, and am not under the influence of any drug or alcohol at this time.
All medications and medical conditions have been disclosed to my technician as well as noted accurately and to the best of my knowledge on my intake/consultation form.
Being of sound mind and body, I hereby release and forever discharge the Technician at Yes Darling Studio from any and all claims of negligence, damages, or legal actions arising from or connected in any way with my PMU/SPMU procedure. I fully accept any and all responsibility for any consequences that might stem from my decision to have a PMU/SPMU procedure performed by Rana Albasha.
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