Secret Beauty

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MEDICAL HISTORY FORM

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Name  ___________________________________.        Date of Birth______________

Age ______          Address_________________________________________________

Phone Number ______________________       Email  __________________________

Emergency Contact Name and Phone.     ____________________________________

Procedure:  Eyebrows  ______ Upper Eyeliner ______  Lower Eyeliner ______

Have you had an allergic skin reaction to pigments or makeup? List all allergies:

_______________________________________________________

 

What Medications are you on? Please list:

___________________________________________________________

Do you have any of the following medical conditions? (Please check all that apply) 

 

___ Cancer                              ___Frequent cold sores   ___ Seizure disorders
___ Any active infections     ___High blood pressure  ___ Herpes

___ Keloid scarring                ___Skin issues                  ___ Blood clotting abnormalities 

___ Arthritis                           ___ Hepatitis                      ___ Diabetes

___ Open wounds                 ___ Liver disease.              ___ Severe hyperlipidemia

___ Defibrillator                    ___ Pacemaker                  ___ Epilepsy

___ Large metal implants    ___ Blood thinners           ___ Renal/Pancreatic disfunction

___ Pregnant                        ___ Breastfeeding             ___ Wear contact lenses 

___ Blood thinners              ___ Had Botox recently.  ___ Under radiation or chemotherapy

___ Glaucoma                       ___ Eczema                       ___ Psoriasis

___ Hepatitis                         ___ HIV/AIDS 

 

Do you any other health problems or medical conditions? Please list: 

____________________________________________________________

 

I certify these statements are true and correct. I am aware that it is my responsibility to inform SECRET BEAUTY of my current medical and or health conditions and to update this history. A current medical history is essential for my safety and for the appropriate procedure plan. 

 

Client Signature ________________________________________    Date _________________ 

 

 

Consent to application of Micropigmentation procedures

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I am over the age of 18, 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. 

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I have been Informed of the nature, risks and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, keloid, Inconsistent color, and spreading, fanning or fading of I understand the actual color of the pigment may be modified sightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science. I request the 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). 

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I hereby consent to the above procedure(s) being done on me and in consideration of their doing so, I hereby and forever discharge SECRET BEAUTY, its officers and employees of and from all claims, demands, damages, actions and cause of action arising out of the performance of the said treatment procedure(s), which I or my heirs executors, administrators, or assigns can, shall, or may have. Being of sound mind and body, I HEREBY RELEASE ANY AND ALL PERSONS REPRESENTING SECRET BEAUTY FROM ALL RESPONSIBILITY.

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I accept all responsibility, myself for any consequences that might stem from my decision to have any tattoo related work done by SECRET BEAUTY 

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I agree that these waivers also pertain to and are designed to protect all establishments where SECRET BEAUTY conducts business. I accept the color, design, and payment terms in and related to this contract.

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Eyeliner procedures: I understand that there is a risk of possible inner eye infection, eye abrasion, or irritation. I accept full responsibility and risks of set procedure. if you are of light eyes, pink skin, or a true red head, if you have very thin, sensitive skin, oily skin, large pores or rosacea hair strokes/ pigment may blur or completely fade and it’s longevity is reduced. The same is true of very dark skin. 

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I have received pre and post procedure 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 am on any medications for depression or any other mood-altering prescription, I will advise my provider. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplation any permanent cosmetic procedure around my lips. 

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Client Signature ________________________________________    Date _________________ 

 

I understand that it 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 that some of these potential adverse changes may not be correctable.

Initial ________

 

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CLIENTS WITH PERMANENT MAKEUP DONE BY OTHER PROVIDERS NOT BY SECRET BEAUTY 

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SECRET BEAUTY will attempt to repair/reconstruct work done by other providers either by salabrasion, camouflage or color correctors. SECRET BEAUTY’s work will be done to the best of our ability with the understanding that it may or may not be possible to achieve perfect results and with the understanding that it could take more than just one touch-up, 

All options have been thoroughly explained to me and I understand that due to my previous work done by other providers I may not be able to achieve perfect results and that it could be lengthy process. 

Initial _______

 

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PHOTOGRAPHY RELEASE 

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I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure(s), as such I consent/authorize SECRET BEAUTY to use photos for any promotional use as in an internet website which is exposed to the public. 

I certify I have read and initialed the above paragraphs and have had them explained to me and I understand this consent and procedure permit. I accept full responsibility for the decision to have this or these cosmetic procedure(s) done. 

 

Client Signature ________________________________________    Date _________________