Personal Information
Do you presently have or previously had any of the following?
Cold Sores/Fever Blisters
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Cold Sores/Fever Blisters
Abnormal Heart Condition
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Chemical Peel
*if yes when was last treatment*
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Chemical Peel
*if yes when was last treatment*
Pregnant or Breastfeeding
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Pregnant or Breastfeeding
Accutane or Acne treatment
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Accutane or Acne treatment
Taking blood thinners such as Aspirin, Ibuprofen, alcohol, Coumadin etc. Or any allergic reaction to them.
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Taking blood thinners such as Aspirin, Ibuprofen, alcohol, Coumadin etc. Or any allergic reaction to them.
List of any allergies in food and medication:
List of any diseases of disorders not listed:
Please list medications or vitamins you are presently taking:
I agree that all the above information is true and accurate to the best of my knowledge.
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I have viewed the risks and complications, contraindications and followed my pre-care.
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Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email my technician.
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Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email my technician.
I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.
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I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.
I understand that sun, tanning beds, pools, medications, and some skin care products can affect my permanent makeup.
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I understand that sun, tanning beds, pools, medications, and some skin care products can affect my permanent makeup.
I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI. I accept the responsibility in explaining to you my desire for specific colour, shape, and positions for any procedure done today.
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I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI. I accept the responsibility in explaining to you my desire for specific colour, shape, and positions for any procedure done today.
I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI. I accept the responsibility in explaining to you my desire for specific colour, shape, and positions for any procedure done today.
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I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI. I accept the responsibility in explaining to you my desire for specific colour, shape, and positions for any procedure done today.
I understand that implanted pigment colour can slightly change or FADE completely over time due to circumstances beyond your control and I will need to maintain the colour with future applications and a touch up session within 60 days.
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I understand that implanted pigment colour can slightly change or FADE completely over time due to circumstances beyond your control and I will need to maintain the colour with future applications and a touch up session within 60 days.
I acknowledge that the proposed procedure(s) has the possibilities of complications during and/or following the procedures such as: risk of infections, misplaced pigment, excessive bleeding, poor colour retention and hyperpigmentation.
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I acknowledge that the proposed procedure(s) has the possibilities of complications during and/or following the procedures such as: risk of infections, misplaced pigment, excessive bleeding, poor colour retention and hyperpigmentation.
I will have my touch up 6/8 weeks after initial apt. After 60 days, a fee will apply and there will be NO REFUNDS for this elective procedure. I may then need more than 1 touch up.
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I will have my touch up 6/8 weeks after initial apt. After 60 days, a fee will apply and there will be NO REFUNDS for this elective procedure. I may then need more than 1 touch up.
I accept full responsibility for the decision to have this cosmetic tattoo and or
micropigmentation work done. I fully understand there is NO REFUND, and this procedure may not
have the outcome I expected.
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I accept full responsibility for the decision to have this cosmetic tattoo and or
micropigmentation work done. I fully understand there is NO REFUND, and this procedure may not
have the outcome I expected.
I certify that I have read the contents of this form. I understand the risks and alternatives in this procedure(s), and I have had the opportunity to ask questions and get them answered. I acknowledge that I have reviewed and approved the material and give authorization for ROISIN, as my permanent cosmetic technician to perform my appointment.
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I certify that I have read the contents of this form. I understand the risks and alternatives in this procedure(s), and I have had the opportunity to ask questions and get them answered. I acknowledge that I have reviewed and approved the material and give authorization for ROISIN, as my permanent cosmetic technician to perform my appointment.
Consent and Release Agreement for Permanent Cosmetics
and Micropigmentation
This form is designed to give information needed to make an informed choice of whether to undergo a permanent cosmetic and micropigmentation application. If you have questions, please don’t hesitate to ask. Although permanent cosmetic tattooing and micropigmentation are effective in most cases, NO guarantee can be made that a specific client will benefit from the procedure. Micropigmentation is not permanent. There is NO REFUND!
Generally, the results are excellent. However, a perfect result is not a realistic expectation. A touch up IS required 6/8 weeks after the healing is completed. YOU MAY NEED MORE THAN ONE TOUCH UP TO ACHIEVE DESIRED RESULTS. MICROPIGMENTATION LASTS 6 TO 18 MONTHS ON AVERAGE. RESULTS VARY PER PERSON.
YOU MAY NEED MORE THAN ONE TOUCH UP TO ACHIEVE DESIRED RESULTS. MICROPIGMENTATION LASTS 6 TO 18 MONTHS ON AVERAGE. RESULTS VARY PER PERSON.
You are SIGNING this KNOWING that colour retention is NOT guaranteed.
Photography and Videography Release
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Before and After photos/videos may be taken and kept on file. We would like your permission to use these photos/videos for advertising of ANY kind.
Photography and Videography Release
Results/Outcome Disclosure
It has been reviewed multiple times that my colour MAY FADE SIGNIFICANTLY and will also FADE IN AND OUT DURING THE ENTIRE HEALING PROCESS. MICROPIGMENTATION AND PERMANENT COSMETICS PROCEDURES ARE NOT FOR EVERYONE, I MAY BE ONE OF THEM.
RESULTS vary (EVEN AFTER HEALING) depending on but not limited to the following:
How your body metabolizes the colour
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How your body metabolizes the colour
Sun exposure (even after healing)
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Sun exposure (even after healing)
Tanning (tanning bed or direct sun even after healing)
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Tanning (tanning bed or direct sun even after healing)
Skin care products/makeup
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Skin care products/makeup
Underlying OR undiagnosed medical conditions
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Underlying OR undiagnosed medical conditions
Use of certain medications
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Use of certain medications
Not following ALL instructions (including aftercare)
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Not following ALL instructions (including aftercare)
Unknown causes (which are beyond any person’s control)
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Unknown causes (which are beyond any person’s control)
PICKING OR SCRATCHING TREATED AREA
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PICKING OR SCRATCHING TREATED AREA
LAKE WATER/ CHLORINATED POOLS AND HOTTUBS
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LAKE WATER/ CHLORINATED POOLS AND HOTTUBS
Chemical peels, microdermabrasion treatment, anti-aging treatments
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Chemical peels, microdermabrasion treatment, anti-aging treatments
Plucking, waxing, threading on treated area
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Plucking, waxing, threading on treated area
Micropigmentation is a superficial, temporary treatment, it is implanted in my lower layer of my epidermis which I am continually exfoliating, everyone exfoliates at different rates. This is NOT permanent and may last 6 months to 18 months realistically but could fade sooner or last longer depending on the above points that I have read through and agree to move forward with my procedure.
To whom this contract may concern, I _____________have carefully read and understand EVERYTHING I have signed and have had all my questions answered, I am choosing to proceed on my own free will and am in a healthy state of mind to do so.
I HAVE CAREFULLY READ EACH AND SIGNED EACH CONSULTATION FORM PRIOR TO STARTING TREATMENT AND I AM CHOOSING TO CONTINUE WITH MY PROCEDURE UNDERSTANDING FULLY AND COMPLETELY.
TYPICAL HEALING SCHEDULE 1
● Day 1-4- They become darker and bolder as they form a scab. This is only temporary, DO NOT PANIC
● Day 5-12- The Scab naturally exfoliates, peels and flakes away over the course of several days. The fresh skin underneath is white or pinkish and may have a waxy coating, making it appear that the brows are too light. It may seem like ALL your colour has fallen off! Be Patient the outcome is wonderful
● Day 10-30- After 10 days you may use brow makeup very gently if you need it. The colour will slowly come back to life and bloom back to the surface as the new, white skin settles in and heals. Wait at least 4 weeks to see the true colour. It is only after 6 weeks that your touch-up/adjustment can be carried out. Your second appointment is to tighten up your shape, touch up any light spots and assess how your skin reacts to the process, and the chosen colour.
● NOT EVERYONE FOLLOWS THE EXACT SAME HEALING SCHEDULE, THIS IS ONLY THE AVERAGE HEALING. YOUR BROWS AND PERMANENT COSMETIC PROCEDURE CAN GO THROUGH NO FLAKING, SOME FLAKING, SCABBING, COLOUR LIGHTENING, COLOUR LOSS, SPOTS THAT FADE, SPOTS THAT DO NOT FADE, IT MAY TAKE MORE THAN ONE TOUCH UP TO ACHIEVE MY DESIRED LOOK, FULLNESSA ND OUTCOME, MIRCOPIGMENTATION, PERMANENT EYEBROWS, PERMANENT EYELINER AND OTHER PERMANENT COSMETIC PROCEDURES MAY NOT WORK FOR ME AND I AM SIGNING THIS SHEET KNOWING THIS AND WILL NOT HOLD TECHNICIAN AT FAULT
TYPICAL HEALING SCHEDULE 2
*POST CARE: For the first 24 hours Blot any Lymph fluid from treated area with a tissue. Scabbing is normal, some scab more than others for a variety of reasons such as bleeding, or the body’s own immune reactions.*
● DAY 1 to 14- Make sure eyebrows are COMPLETELY dry, do not get them wet or apply any make up, creams etc
● Do not rub, pick, or scratch the treated area. Let any scabbing or dry skin naturally exfoliate off. Picking can cause scarring and pigment loss!
● Avoid sun exposure and tanning beds for a minimum of 4 weeks after your procedure. Direct sunlight can cause the pigment to change colour while healing and can also cause hyper pigmentation and scarring
● Avoid pools, saunas, steam rooms, hot showers and or hot baths for 10 days.
● Avoid Sweating on your face for 10 days. Sweating through or on the brows will expel pigment form the dermis producing poor results.
● Avoid sleeping on you face for the first 10 days!
● No makeup or skincare products to be used on the treated are for 10 days.
● Keep you bangs, and hair pulled back from face.
● After 10 days, once the area has healed completely, use sunblock when going out in the sun to stop the colour from fading.
● Do not tint eyebrows for 2 weeks after procedure.
● Avoid Retin-A, Chemical Peels, Laser Treatments, Microdermabrasion, and/or anything to treat hyperpigmentation around brow area to prevent fading.
Permanent Cosmetics Contraindications
● Pregnant or lactating women
● Skin conditions such as psoriasis, eczema any undiagnosed rashes or blisters on the site that is to be treated, keloid scaring
● Easily triggered post inflammatory hyperpigmentation
● Transmittable blood conditions like HIV or Hepatitis
● Uncontrolled high blood pressure or mitral valve disorder
● Anaemia or other abnormal bleeding conditions
● EXISTING TATTOO ON DESIRED PROCEDURE AREA
*Flu or Cold: Please stay home, reschedule your appointment if you have a cold or flu or sinus/respiratory infection*
*Eye lift or blepharoplasty: Wait 3 months*
Possible Risks and Complications (initial points)
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