Date of Birth:
Address City State Zip Code:
Cell Phone: Emergency Contact Phone:
Procedure Cost Procedure:
_______ I certify that I am over the age of 18, I am not under the influence of drugs or alcohol, I am not pregnant or nursing, and I consent to receiving the indicated micro-pigmentation or permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.
______ 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, scarring, inconsistent color, and spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. 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.
_______ There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. If waived, I release the technician from liability if
I develop an allergic reaction to the pigment. 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 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 medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.
_______ I understand that before and after photographs of the said procedure/s are conditions of such
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 and understand that there is a no refund policy. I understand that the cost of touch-upʼs are not included in the procedure and the cost of touch upʼs differs as time lapses from the original date procedure was done.
Client Signature: Date:
Artist Name: Date:
Artist Name: Date:
Artist Name: Date:
In order to provide you with the most appropriate treatment, please complete the following questionnaire. All of the information is strictly confidential.
Are you currently under the care of a physician? Yes / No If yes, for what?
Do you have any of the following medical conditions/problems? (please circle yes or no)
YesNo High blood pressure
YesNo Frequent cold sores
YesNo Skin disease
YesNo Blood clotting
YesNo Seizure disorder
YesNo Hormone imbalance, abnormality
YesNo Any active infection
YesNo Keloid scarring
YesNo Thyroid imbalance
Other: Have you ever had an allergic reaction to any of the following? (circle yes or no)
YesNo Tattoo pigments
Other allergies. What reaction does your allergy cause?
What oral medications and dosage are you presently taking? (please list)
What Vitamins or Supplements are you taking? (please list)
What topical medications, cleansers, or, creams are you currently using on your face? (please
Have you recently had treatments such as facials, peels, microdermabrasion, etc. on your face?
Yes / No (please list)
Do you form thick or raised-scars from cuts or burns? Yes / No YesNo
Do you get Hyper-pigmentation (darkening of the skin), Hypo-pigmentation (lightening of the
skin) or marks after physical trauma? YesNo
Which of the following best describes your skin type? (please list)
Always burns, never tans
Always burns, sometimes tans
Sometimes burns, always tans
Rarely burns, always tans
Brown, moderately pigmented skin
Have you had any recent tanning or sun exposure that changed the color of your facial skin?
Are you pregnant or trying to become pregnant? YesNo
Are you breastfeeding? YesNo
Are you using contraception? YesNo
________ I certify that the preceding medical, personal, and skin history statements are true
________ I am aware that it is my responsibility to inform the technician, of my current medical
conditions and to update this history.
________ A current medical history is essential for the permanent makeup technician to execute
Permanent Makeup Policies
Permanent makeup is all about you! We want to provide you with the highest standards of
service and personal care, in the most professional environment so that you will return and
recommend our services.
Cancellation – If you have an appointment, this time is reserved exclusively for you. In the event
that you must cancel your appointment, we require a 72-hour cancellation notice in advance for
Late Arrival – Arriving late will deprive you of valuable service time. As a courtesy to the next
guest, your treatment will end at the time originally scheduled. Late arrivals may be
rescheduled, or the remainder of the service time may be used at full price.
Children Under 18 – Due to liability reasons no children under 18 are allowed in the treatment
area. We want to provide the best relaxation atmosphere for our clients. Thank you for your
Cell Phones –Cell phone use is not permitted while permanent makeup services are rendered.
Permanent Makeup Done by Another Technician – Recoloring permanent makeup done
previously by anyone else is not “just a touch-up” since it is not the original work of our Provider.
Therefore, fees start at the new permanent makeup prices. Two or more appointments may be
necessary to achieve and complete most permanent makeup correction procedures. Note:
Permanent Makeup Maintenance / TOUCH-UP – Touch-upʼs are not included in the original
Pricing – All prices quoted are subject to change without notice. All purchases and services are
final, and there are NO refunds.
Additional Treatment Policy
1. We reserve the right to refuse services to anyone.
2. Two or more appointments may be necessary to achieve and complete most permanent
makeup procedures depending on each personʼs skin. Touch-up fees will apply.
3. Since scar tissue is abnormal, multiple sessions are usually needed to achieve satisfactory
results with medical grade tattooing/camouflage.
4. Only clients receiving service will be allowed within the treatment room.
I have read, understand, and agree to all of the Policies listed above.
Request and Consent to Photography and/or Video Record
Your provider may need to photograph and/or record you to document a medical condition, help with diagnosis and/or treatment of a condition, and/or to help plan the details of a treatment. Photographs and/or recordings taken for these clinical reasons do not require your written permission. Your provider does need your written permission to use your photographs and/or recordings for the non-clinical reasons below.
I hereby authorize iOWA iBROW iLASH ACADEMY, including the attending students or other designated
person(s), to photograph and/or video me for the following purposes: Yes
YesNo 1. For the advancement of not-for-profit medical purposes, including teaching, research,
! ! and education. I understand that education is an important part of iOWA iBROW iLASH
! ! ACADEMYʼs commitment to teaching Tattoo Artist providers.
YesNo 2. To show or release to current or future iOWA iBROW iLASH ACADEMY patients for the
! ! purpose of education and consultation. I understand these photos or videos can be taken
! ! at any time during my treatment which includes pre-treatment, post treatment,
! ! pre-operative, intra-operative, post-operative photos, and/or videos of my treatment,
! ! surgery and/or procedure.
YesNo 3. For external not-for-profit educational purposes outside Alchemy Aesthetic Institute
! ! such as lectures, presentations at professional conferences, news publications, website
! ! publications, social media posts, and email blasts.
YesNo I consent to photographs and/or video recordings under the following conditions:
________ Copies of the photos, videos, and/or films may be released to me if I ask for them.
________I can refuse to have photos and/or video taken without any change in my patient care at iOWA
iBROW iLASH ACADEMY.
________ I understand and agree that although my name will not be used, it may be possible to identify me from a photo and/or video.
________ I understand that once released outside of Alchemy Aesthetic Institute, Alchemy Aesthetic
Institute does not have control over the photos or videos.
This authorization has no expiration date; however I may revoke it at any time by writing to iOWA iBROW iLASH ACADEMY at154 SE LAUREL ST. WAUKEE IA. 50263. I must state in writing that I no longer give consent for photo(s) and/or video(s) or for the use of any photo(s) or video(s) that were already taken. I have read and understand the information. I hereby release iOWA iBROW iLASH ACADEMY, its personnel, and any other persons participating in my care from any and all liability which may or could arise from the taking or unauthorized use of such photographs and/or video recordings.