Permanent Makeup - Nederland & Lumberton, TX

Permanent makeup Nederland TX consent form. Please fill out this form on your first appointment. Your answers help us meet your needs. They also help ensure a happy, satisfying experience.

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Your beauty journey starts with this consent form. Please fill it out before your first visit. As a result, your artist can plan a safe service.

Permanent Makeup in Nederland TX

Permanent makeup adds soft color that lasts. For example, choose microblading, combination brow shading or lip blush. In addition, every service starts with a consultation. That way, your shape and shade suit your face. See our gallery for real results.

Book Your Appointment

First, choose your studio. You can visit us at 3205 Nederland Ave (Google Maps). Alternatively, stop by 211 S Main St in Lumberton. Then book in Nederland or book permanent makeup in Lumberton, TX. Also, see prices on our services page.

Full Name: *

Email *

Date of Birth: *

Phone *

Address: *

Emergency Contact Phone *

Have you ever had a cosmetic tattoo or permanent makeup procedure before? *

Yes No, If yes, when was your last procedure?

What would you like to improve about your eyebrows/lips/eyes/scalp/areola? (Consider shape, color, density, thickness) *

Do you have moles/rasied areas in or around the brow area? Do you have *

Yes No

or have had a piercing in the brow area? *

Yes No

Have you had a hair transplant for your eyebrows? *

Yes No

FEMALE CLIENTS ONLY Are you, or is it possible you may be pregnant? *

Yes No

Are you currently breast feeding? *

Yes No

MEDICAL QUESTIONNAIRE

For a more effective, personalized treatment, please be as accurate as possible when filling out the following information

Are you prone to keloid scarring, hypertrophic scarring, or any other form of excessive scarring condition? *

Yes No

Have you taken a medication containing Isotretinoin (e.g. Roaccutane) during the previous 12 months? *

Yes No

Do you have, or do you think it is possible you may have a Blood Borne Communicable Disease? e.g. Hepatitis C Virus (HBC), Hepatitis B Virus (HBC), Human Immunodeficiency Virus (HIV) Yes No *

Yes No

Do you currently have any other form of communicable disease, or infection?, e.g. Respiratory infection, gastrointestinal infection, skin infection, ear or eye infection, bacterial, fungal or viral infection, etc. *

Yes No

Do you have Diabetes, currently on any form of immuno suppressant therapy, or have any other condition that may cause delayed healing? *

Yes No

Have you ever had a Herpes Simplex Type I infection (also called cold sores/fever blisters)? *

Yes No

Do you have any Hypersensitivity, Auto-Immune Disorder, or Allergic Conditions? *

Yes No

Do you have a known allergy or sensitivity to any topical or local anesthetics including dental anesthetics? *

Yes No

Have you ever taken a medication containing Bisphosphonate/Diphosphonate? (e.g. fosamax, alendronate) *

Yes No

Do you have any form of bleeding disorder, or are you taking any anticoagulants (blood thinners)? *

Yes No

Have you had any form of Cosmetic or Surgical Procedure, Radiotherapy, or Chemotherapy at any time during the past 6 months? *

Yes No

Do you suffer from any form of hyper-pigmentation skin conditions? *

Yes No

Do you suffer with fainting, blackouts, or seizures? *

Yes No

MEDICAL DEVICES & CONDITIONS

Do you have a cardiac pacemaker, Implanted Cardioverter Defibrillator (ICD), have a serious heart condition, or abnormal blood pressure? *

Yes No

Do you have any form of acute or chronic eye condition? *

Yes No

Are you prone to developing Telangiectasia? (sometimes referred to as spider veins) *

Yes No

Do you suffer from allergies? *

Yes No

Are you currently taking any medications, herbs, vitamins? *

Yes No

Do you have an allergy or sensitivity to latex/rubber? *

Yes No

Do you smoke? *

Yes No

Do you have a known allergy or sensitivity to any ingredients within tattoo pigments or needles, regular makeup, any preservatives, hair dyes, or other dyes? *

Yes No

Do you have a known allergy or sensitivity to any ingredients in tattoo aftercare creams,antiseptics, lanolin, or petrolatum (petroleum jelly)? *

Yes No

Have you used any eyelash or eyebrow growth serums / creams or any eye drops that may contain prostaglandin analogues in the past 4 weeks? *

Yes No

Do you wear contacts? *

Yes No

Is there any additional information about you that we should know before starting your treatment? *

ABOUT SEMI-PERMANENT MAKEUP

Please read the following statements carefully. Semi-Permanent Makeup procedures are a way of cosmetic tattooing, intended to be semi-permanent lasting an average of 12 - 36 months. On rare occasions, the pigment may migrate under the skin. The procedure of permanent makeup may be uncomfortable. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be performed if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after microblading procedure, you should notify/discuss with your doctor. Possible scarring may occur. I have received after care information and I'm fully aware of the after care procedures. I fully understand the information provided above & confirm that all information provided by me is correct and truthful.

Client (Printed Name) *

Technician Name *

Client Signature *

Technician Signature *

Date PN *

Date TN *

For Technician Use Only - Notes: *

INFORMED CONSENT

I hereby consent to and authorize my technician *

to perform my permnanet makeup procedure.I, *

, am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated permanent makeup procedure. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed, has been explained to me.

CLIENT ACKNOWLEDGEMENTS

HEALTH CHECK

Are you pregnant, nursing or trying (IVF) to get pregnant? *

Yes No Maybe

For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s). APPROVE *

Approve Decline

For the purposes of education or assistance, I consent to the admittance of authorized observers to the procedure(s). *

Approve Decline

Service Termination & Legal Agreement *

My technician can release me at any time from any future services if they feel policies or procedures are not followed. I have read and fully understand the contents of each paragraph above. I acknowledge this is a legal & binding contract and that I have

No Warranty Disclaimer & Mental Competence *

received no warranties or guarantees with respect to the benefits to be realized from or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.

Client (Printed Name) *

Client Signature *

CONSENT DATE

Date *

Technician *

DISCLOSURE & RELEASE FORM

PHOTO/VIDEO CONSENT FORM

I, *

, hereby grant permission to the rights of my image, likeness and sound of my voice as recorded in audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published, or distributed. I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

PHOTOGRAPHIC, AUDIO, OR VIDEO RECORDINGS MAY BE USED FOR THE FOLLOWING PURPOSES:Educational presentations or coursesInformational presentationsOnline educational coursesEducational videosPromotional materials

By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the internet or in the public educational setting. *

I will be consulted about the use of the photographs or video recordings for any purpose other than those listed above. There is no time limited in the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio, or video recordings collected as part of the sessions listed on this document only.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

CLIENT SIGNATURE

Client (Printed Name) *

Client Signature *

Date *

Field *

Fairy - Nederland Tx

Fairy - Lumberton Tx

Business hours

Permanent Makeup - Nederland & Lumberton, TX

Permanent Makeup in Nederland TX

Book Your Appointment

MEDICAL QUESTIONNAIRE

MEDICAL DEVICES & CONDITIONS

ABOUT SEMI-PERMANENT MAKEUP

INFORMED CONSENT

CLIENT ACKNOWLEDGEMENTS

HEALTH CHECK

CONSENT DATE

DISCLOSURE & RELEASE FORM

PHOTO/VIDEO CONSENT FORM

CLIENT SIGNATURE

Contact us

Business hours

Fairy - Nederland Tx

Fairy - Lumberton Tx

Fairy