Form
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Address (please include your postal code)
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact (Name and Contact Number)
*
Have you ever had a cosmetic tattoo or permanent makeup procedure before? If yes, when was your last procedure?
*
Yes
No
If yes, kindly specify:
Have you experience Collagen injections, Botox, or Reslylane?
*
Yes
No
If yes, kindly specify:
For the last 2-3 weeks, have you undergone any surgery or plastic surgery?
*
Yes
No
If yes, kindly specify:
Medical History
Please answer all the questions to the best of your knowledge
Please mark any of the following conditions you may currently have:
*
Acne Vulgaris
Rosacea
Eczema (Dermatitis)
Psoriasis
Cold Sores (Herpes Simplex Virus)
Fungal Infections (e.g., Tinea)
Bacterial Infections (e.g., Impetigo)
Viral Infections
Allergic Contact Dermatitis
Seborrheic Dermatitis
Pityriasis Rosea
Scleroderma
Hyperpigmentation
Hypopigmentation
Pruritus (Itching
Spider Veins (Telangiectasia)
Milia
Dermatosis Papulosa Nigra (DPN)
Acanthosis Nigricans
Ichthyosis
Hives (Urticaria)
Warts
Cystic Acne
Cellulitis
Melasma
Vitiligo
Xerosis(Dry Skin)
Actinic Keratosis
Keloids
Lichen Planus
N/A
Please mark any of the following conditions you may currently have:
*
Peptides
Ceramides
Glycolic Acid
Lactic Acid
Benzoyl Peroxide
Alpha Hydroxy Acids (AHAs)
Beta Hydroxy Acids (BHAs)
Niacinamide
Retinoids (Retinol, Retin-A)
Vitamin C (Ascorbic Acid)
Hyaluronic Acid
Salicylic Acid
N/A
Have you recently received any of the following treatment?
*
Facial Peel
Microdermabrasion
Microneedling
HydraFacial
Radiofrequency (RF) Treatment
Cryotherapy
Laser Hair Removal
Laser Skin Resurfacing
Chemical Peel
Botox or Dermal Fillers
LED Light Therapy
Electrolysis
N/A
Health History
Please answer all the questions to the best of your knowledge
Have you used or been prescribed any medication(topical or oral) for acne/acne control?
*
Yes
No
Have you ever experienced claustrophobia?
*
Yes
No
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
*
Yes
No
FOR FEMALE CLIENTS ONLY- Are you taking birth control? (Click NO if the question is not applicable to you)
*
Yes
No
FOR FEMALE CLIENTS ONLY- Are you pregnant or trying to become? (Click NO if the question is not applicable to you)
*
Yes
No
Are you undergoing any hormone replacement therapy?
*
Yes
No
Consent
Please pay attention to each question. Checking the box means you understand and agree on the statements.
This consent/waiver is for:
*
Initial Treatment
Touch-Up Visit
Type of procedure (Please mark all that applies)
Brows (Microblading, Ombre/Microshading, Hybrid/Combo Brows, Nano)
Lip Liner/Blush
Scar Camouflage
Stretch Mark Camouflage
Scalp Pigmentation
Has there been any changes to you health since your last visit at Calix Glow?
*
Yes
No
N/A, this is my first visit
If yes, please specify:
Tattoo inks, dyes, and pigments have not been approved by the Federal of Food and Drug Administration, and the health consequences of using these products are unknown.
I have read the above information regarding tattoo inks, dyes, and pigments and the FDA, and that the health consequence of using these products are unknown.
I understand that the manufacturer of the pigment to be applied requires spot-testing and specifically disclaims any adverse reaction to applied pigments. Spot testing may identify individuals who develop an immediate allergic reaction to pigments only. Allergic reaction to pigments are rare, however, they can and do occur and when they happen they can be serious and especially difficult and troublesome to treat
Please read all the statements and check if you agree:
I am over the age of 18, and I am not under the influence of drugs and alcohol and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.
I am aware that the noted permanent skin pigmentation procedure will most likely involve pain and discomfort. Numbing cream may be used, but does not always provide total relief. These creams can also alter the texture of skin, making it "spongy" after the cream is applied, making the skin resistant to absorbing the pigment. Therefore, if used, the numbing cream may be applied halfway or at the end of the procedure.
I am aware that there are risks and possible complications and consequences of permanent skin pigmentation procedures. The procedure carries with it unknown complication and consequences, including but not limited to: infection, allergic reaction, scarring, hyperpigmentation, inconsistent color, and spreading, fanning or fading of pigments. The actual color of the pigment may be modified slightly, due to the tone and color of my skin. This is the tattoo process and therefore not an exact science, but an art. I request the above noted permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s). I understand that no warranty or guarantees have been made to me regarding the results nor should be inferred.
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.
I accept full responsibility for any and all present and future medical treatment and expenses I may incur in the event I need to seek medical treatment for any known or unknown reason association with the procedure received.
I understand that touch-up procedures will most likely be required 6-8 weeks after the initial service for color and/or shape correction. If I cancel or if I "No show" the appointment, or do not reschedule at least 72 hours before the scheduled appointment, or if my touch-up appointment takes place more than 8 weeks after my initial procedure (unless approved by the practitioner_, or have rescheduled more than 2 times, I will no longer be eligible for the complementary touch-up appointment.
I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so many jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my practitioner. If I have ever had cold sores, I will consult with and strictly follow my doctor's instruction before contemplating any permanent cosmetic procedure around my lips.
I have been given an opportunity to ask questions about the procedure and the procedure to be used and the risks and hazards involved and I believe that i have sufficient information to give informed consent.
I understand that the taking of before and after photographs of the said procedure(s). I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.
I give permission to use my photos for the purpose of marketing. My pictures appear in print or online.
Yes
No
I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
Name:
*
Date signed:
*
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Month
-
Day
Year
Date
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