GENDER:
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Male
Female
N/A
Name
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First Name
Middle Name
Last Name
D.O.B.
DD/MM/YY
Phone Number
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-
Area Code
Phone Number
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you came across me? and why did you chose me as your artist?
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Emergency contact: name and contact nr.
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Cosmetic tattoo procedure(s) desired:
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Eyebrows - new
Existing tattoo colour refresh
Lash enhancement
Lips
Tattoo removal
Other
Please describe what results are you hoping for from your treatment? and why or how this treatment will help you?
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Please upload a clear photo (without makeup) of the area wanting to get tattooed
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Have you ever had an allergic reaction to any of the following and what happened?
Foods
Metals
Lidocaine/Lignocaine/Novocaine
PABA
Previous tattoo ink or pigment
Dental/local anaesthetic injections
In order to perform the tattoo procedure in a safe manner, please answer the following health questions truthfully. Do you suffer from the following diseases or are you taking any of the following medication?
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Hemophilia
Diabetes mellitus (Diabetes) ( a letter from Doctor is required before treatment can proceed )
Hepatitis
HIV
Skin deseases
Ezcema
Autoimmune desease
Are you prone to herpes
Epilepsy/Seizures
Cardiovascular problems
Are you taking any blood thinners or taking any anticoagulants such as aspirin, ibuprofen, alcohol, q10, coumadin..
High or low blood presure
Glaucoma
Cataracts
Blurred vision
Dry eyes
Thyroid conditions (some medications may cause faster fading of pigments)
Alopecia Universalis (total)
Alopecia Areata (local)
Do you pull out lashes and/ or eyebrows compulsively? (trichotillomania)
Eyelash extensions (for eyeliner only) please note eyelash extensions MUST BE removed at least 3 days prior to eyeliner tattoo)
Collagen/restalyn, botox or other injections on the face
Laser/ipl/fraxel/skin needling treatments
Are you currently tanned in the area to be tattooed?
Do you consider your skin to be oily/ visible pores?
Do you currently use retin a or glycolic acid on your face?
Do you have any keloid or hypertrophic/ raised scars?
Are you currently undergoing treatment for cancer?
Are you pregnant or nursing?
Did you undergo any surgery in the past 14 days?
N/A
Other
I have answered the above questions truthfully and honestly.
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Client name and date:
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CONTRACTUAL OBLIGATIONS
I agree on photo taking and using the photos for advertising and training purposes. YES / NO
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The following risks are specifically explained to the client:During the procedure despite the staff expertise and all the precautionary measures, injury is possible. Despite the application of the most advanced and the top quality pigments, allergic reaction is possible but rare. The client is informed about this and he/she assumes liability.
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Notice that 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.
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During and after the procedure temporary swelling, redness and/or itching may occur.
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Depending on the skin structure after the first treatment small scabs with a loss of drawn hairs may occur and color intensity may change.
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In the first seven days eyebrows are up to 40% darker and 10-15% thicker. Color i.e. color reflection depends on the natural skin pigment.
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The pigment is absorbed differently due to differences in the skin quality, thus there is no warranty for the treatment success.
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The shape is determined according to the face proportions.
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Depending on the skin structure it should be noted that change in the color intensity is possible and that one or more additional treatments will be required.
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The minimum or maximum duration of microblading or permanent makeup procedures cannot be determined with certainty, nor can the warranty be given on performed treatment.
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Any touch ups fees may apply for future appointments if touch ups are desired. If most of the color has faded then this will not be considered a touch up and all fees for a new service may apply. Touch ups are usually performed after 6-8 weeks. For oily skin it may be necessary to perform more corrections.
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Permanent make-up always leads to the skin injury. Therefore, it is important to carefully and gently nurture your skin after the treatment to allow healing without complications. Inadequate care in healing phase of the skin can lead to poor results and LASTING DEFINITION and the technicians cannot be liable for it.
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Permanent Makeup is an art and not science. Client’s result will vary and using a makeup pencil or brow powder may still be needed.
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If skin is oily or sweaty make sure you clean the skin when necessary
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LASTING DEFINITION are not liable in case of improper post-treatment care.
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Absolutely NO refunds after any services will be given.
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I ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN MADE TO ME CONCERNING THE RESULTS OF THIS PROCEDURE.
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I confirm that I have read and understood the above mentioned information.
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I received a clear and understandable response to all my questions.
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The treatment procedure and post-treatment care was explained to me in detail and I agree with it.
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After Care instructions to take home were given me.
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LASTING DEFINITION model/client signature or full name
*
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