Health Questionnaire

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Are you taking any medicine

YesNo

Are you allergic to latex/lanolin/epinephrine/lidocaine?
YesNo

Do you have diabetes?

YesNo

Are you using any exfoliating agents, such as AHA, Retina A, Glycolics or undergone Laser treatment/Chemical Peels/Surgery of any kind

YesNo

Do you have any heart illness/condition or taking any heart medication ?

YesNo

Do you have any blood disease, Hepatitis, HIV, Aids/Hepatitis/Epilepsy?

YesNo

Are you prone to Herpes Simplex (cold sores/fiver blisters)?

YesNo

Are you pregnant or nursing?

YesNo

Have you undergone Chemotherapy?

YesNo

Do you have any problem healing, or Keloid condition?

YesNo

I acknowledge I am over the age of 18, am not under the influence of any drug or alcohol.

YesNo

Informed Consent Form

I acknowledge by signing this consent/release form I have been given the full opportunity to ask any and all questions about obtaining permanent make-up ,and that all of my questions have been answered to my full and total satisfaction. I have been advised of the following and agree:

I acknowledge that obtaining permanent make-up is my choice alone. The application of permanent make-up will result in a permanent change to my appearance, and that needles and pigments will penetrate the surface of my skin. No representations have been made to me as to ability to later restore the skin involved in permanent make-up to the original condition, and it is very costly to remove.

I acknowledge infection is always possible as a result of permanent make-up application. I was given proper skin care instructions, which I am to follow. I acknowledge that should my skin become infected due to improper skin care; I will hold operator harmless.

I agree to follow all suggested instructions concerning the care of the permanent make-up site while it is healing. Otherwise permanent make up may fade more quickly or not yield satisfactory results.

I understand that the final results, shape and color of my permanent makeup are dependent on my aftercare, skin type, lifestyle, age, immune system, metabolism and environment.

I understand that the permanent make-up site usually takes 2 weeks or longer to heal.

I acknowledge that the follow touch up is not included in the price of the initial appointment.

I acknowledge that if I need to reschedule my appointment, I may do so in 72 hours before my scheduled appointment. Otherwise I will lose my deposit, and an additional deposit will be required to make a new appointment.

Clients who already have permanent make up and will be undergoing correction treatment are advised that this is possible that the deeper and/or older pigmentation, color may show back up after a certain time and/or dominate because of chemical composition. We do not provide guaranteed results for this treatment process.

I do not have epilepsy, diabetes, allergic reaction to latex or antibiotics, hemophilia or other bleeding disorder. I do not have cardiac valve disease or suffer from any heart condition or take medications that thins my blood, I’m not pregnant or lactating.

If suffer from hepatitis, or other risk factors for blood borne pathogen exposure, or any other communicable disease I have informed the Technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my permanent make-up procedure.

I do not suffer from any medical or skin condition(s) such as, but no limited to: keloid or hypertrophic scarring. psoriasis at the site of the permanent make-up, or any open wounds or lesions at the site of the tattoo.

I do not have a history of medication use or currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.

I have advised the Technician of any allergies to latex, soaps, or medications. I acknowledge it is not reasonably possible for the Technician to determine whether I might have allergic reaction to the permanent make-up procedure and further acknowledge that such reaction is possible.

I understand that 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 acknowledge and give consent to the studio to use images of my permanent procedure for marketing and, or publishing purposes in various media such as the internet, magazine, printed, and or television etc.

I am not under the influence of any drugs or alcohol.

I do not have any physical, metal, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have permanent make-up at this time.

Persons younger than 18 years of age cannot obtain any tattoo without parent