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Semi-Permanent Makeup
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Facials
Hair Removal
Lash + Brow
Makeup
Manicures + Pedicures
Massage + Body Treatments
Semi-Permanent Makeup Consent/Intake Form
1
Patient Information
2
Medical History
3
Possible Risks
4
Consent Information
5
Final Intake Waiver
Patient Information
Full Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Email
(Required)
Phone Numer
(Required)
Emergency Contact Name
(Required)
Emergency Contact Phone Number
(Required)
Medical History
Do you have an autoimmune disease (DIABETES, LUPUS ETC.)?
(Required)
Yes
No
Botox?
(Required)
Yes
No
Last Treatment
MM slash DD slash YYYY
Area Treated
Are you currently pregnant or nursing?
(Required)
Yes
No
Any heart conditions?
(Required)
Yes
No
Alcohol in the last 24 hours?
(Required)
Yes
No
Do you have body tattoos?
(Required)
Yes
No
Do you heal well from small wounds?
(Required)
Yes
No
Use at Home Exfoliants?
(Required)
Yes
No
Do you bruise easily?
(Required)
Yes
No
Does your skin swell easily?
(Required)
Yes
No
Ever tested positive for HIV and/or Hepatitis (A,B,C,D) and or TB
(Required)
Yes
No
History of MRSA (Methicillin-resistant Staphylococcus aureus)?
(Required)
Yes
No
Any allergies (Lidocaine, Nickel, Coconut etc.)
(Required)
Yes
No
Allergies
Do you have oily skin?
(Required)
Yes
No
Cancer?
(Required)
Yes
No
Year
MM slash DD slash YYYY
Currently on Chemotherapy/Radiation?
Any history of Keloid Scarring?
(Required)
Yes
No
Face/Brow or Forehead Lift?
(Required)
Yes
No
Year
MM slash DD slash YYYY
Are you currently taking any medications (imamunisuppresent, anti-inflammatory / steroid or blood thinner?
(Required)
Yes
No
Are you able to take an over the counter antihistamine? (Ex. Benadryl)
(Required)
Yes
No
Any other medical conditions or concerns not listed:
(Required)
Yes
No
Other Medical Condition
Do you have epilepsy or a history of dizziness or fainting?
(Required)
Yes
No
Have you ever been advised to take antibiotics prior to dental surgery?
(Required)
Yes
No
Any other information you feel significant to inform your technician?
Possible Risks (Initial All)
Pain: There is a possibility of pain or discomfort even after topical anaesthetic has been used.
(Required)
Infection: Although rare there is a risk of infection. Areas treated must be kept clean.
(Required)
Uneven Pigmentation: This can result from poor healing, infection or other causes beyond Third Avenue spas control.
(Required)
Asymmetry: Every effort is taken to avoid asymmetry but our faces are not symmetrical so adjustments may be needed at the mandatory 4-6 week touch up.
(Required)
Allergic Reaction: There is always a possibility of an allergic reaction to the pigment, blade or anesthetic used. You may take a 24 hour patch test to determine prior to treatment.
(Required)
Unpleasant Results: I understand that tattooing is permanent and choosing to have it removed can be costly and cause scarring.
(Required)
Infection: If you ever suspect signs of infection seek medical attention immediately.
(Required)
Consent Information (Initial All)
Aftercare instructions have been explained and I fully understand them.
(Required)
I fully understand possible risks and assume any and all liability associated with this procedure.
(Required)
I understand this service is not complete without a 4-6 week touchup.
(Required)
It has been recommended to perform a patch test prior to any Micro-pigmentation procedure; however, I do not want a patch test against recommendation of the technician and I am waiving the patch test. Initial only if you are waiving.
(Required)
Any allergies to any numbing agents including any “CAIN” ingredients.
(Required)
I am not under the influence of drugs or alcohol.
(Required)
I am the person on the legal ID presented as proof that I am at least 18 years of age
(Required)
Consent
(Required)
I agree.
I, have been fully informed of the risks of tattooing including but not limited to infection, scarring, difficulties in detecting melanoma, an allergic reaction. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application and I assume any and all risks that may arise from tattooing.
Client Signature
(Required)
Today's Date
(Required)
MM slash DD slash YYYY
Final Intake Waiver (Initial All)
I understand there are no refunds issued for any brow service.
(Required)
I understand and acknowledge that I have been advised to avoid washing the brow area for three days, refrain from using exfoliants, avoid tanning beds, and to apply a thin layer of coconut oil to prevent scabbing.
(Required)
The undersigned further accepts full responsibility for indemnities and holds Third Avenue Spa harmless and without liability of any kind whatsoever of the pigment and coloration and position of all micro pigmentations.
(Required)
The undersigned further understands and acknowledges that all of the procedure contempt and consented to herein have been fully explained and undersigned fully understands the nature, scope and repercussions of the procedures herein Third Avenue Spa Intake Form 4 of 4 consented to being performed and the undersigned herein fully accepts responsibility for any and all results of the said procedure.
(Required)
The undersigned further acknowledges that any information provided by the undersigned to Third Avenue Spa is being provided for the purpose of Third Avenue Spa own internal compilation of information and under no circumstances is it being deemed to be given for the purpose of Third Avenue spa or any of its employees giving or making any medical decision, opinion, diagnosis or representation to the undersigned.
(Required)
The undersigned in consideration of Third Avenue Spa completing the above described procedures hereby forever release and further agrees not to make any claim or demand or commence, loss or any relief whatsoever against Third Avenue Spa in respect of any cause, matter of thing whatsoever existing or relating to the procedures performed as described herein.
(Required)
The undersigned further agrees that this release shall operate conclusively as an estoppels in the event of any such claim, action or proceeding and may be pleaded accordingly.
(Required)
This release shall be deemed to have been made and shall be constructed in accordance with the Laws of the Province/Territory and/or State in which signing took place as set below.
(Required)
Consent
(Required)
I agree.
By signing below I agree that I have discussed the procedure in its entirety with my technician. I have also discussed all personal information, allergies, medical history, medications and concerns that I may have.
Client Signature
(Required)
Client Name
(Required)
First
Last
Untitled
Email
This field is for validation purposes and should be left unchanged.
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