MUST COMPLETE FORM PRIOR TO SCHEDULING APPOINTMENT! CALL 770-744-1527 FOR APPOINTMENT.

Name (required)

Email (required)

Date of Birth (required)

Phone (required)

Emergency Contact Name (required)

Emergency Contact number (required)

How were you referred? (required)

Which permanent makeup service(s) are of interest to you? (Check all that apply.) (required)
 Hairstroke eyebrows Eyeliner Lips

Are you currently wearing permanent makeup? (required)
 Yes No

If yes, please send a clear picture of your current permanent makeup. If no, please send a picture of the area(s) you would like tattooed. BEFORE YOU SUBMIT THIS FORM YOU MUST ATTACH A PHOTO of the areas you would like permanent makeup applied. (required)

I understand that ALL SEMI-PERMANENT COSMETIC PROCEDURES ARE MULTI-SESSION PROCESSES. An initial application is incomplete until after a follow-up appointment, which must be scheduled approximately 4 weeks after my initial appointment. There is no additional charge for the follow-up appointment after my initial application as long as it is performed within 4 weeks of the initial application. (required)
 Yes No

I understand that WHILE MY SKIN HEALS, I WILL BE PREPARED FOR THE COLOR INTENSITY OF MY PROCEDURE TO BE SIGNIFICANTLY LARGER, SHARPER, BRIGHTER, OR DARKER than what is expected for the final outcome. This is a normal and expected result of the application and healing process. The healing process will take a number of days to complete, depending on how quickly the outer layer of my skin exfoliates and new skin regrows to take its place. (Since delicate skin or sensitive areas may swell slightly or redden, some clients feel it best not to make social plans for a day or two following any procedure.) (required)
 Yes No

Eyebrows: I understand that I must avoid tweezing, waxing, electrolysis, and coloring my brows for two weeks prior to the procedure if possible. This will allow my practitioner the most flexibility to achieve optimal results. (required)
 Yes No

Eyeliner: I understand that I MUST NOT WEAR CONTACT LENSES DURING OR IMMEDIATELY FOLLOWING THE PROCEDURE. Remember to bring my glasses. I may resume wearing my contact lenses as soon as my eyes return to their pretreated condition. Do not use growth stimulants such as Latisse®, RapidLash®, or RevitaLash® for at least one week prior to and one week after my eyeliner procedure. (required)
 Yes No

Lips: I understand that if I have any history of cold sores/ fever blisters/ herpes simplex, I must contact my physician to obtain and take the proper prescription medication to prevent such outbreaks for at least 3 days before and after the original procedure and any followup procedures. Many physicians prescribe 12 capsules of 500mg Valtrex. Follow my physician’s instructions. Two or three applications may be required to achieve the desired results. It is not uncommon to lose up to 70% of the color on the first application. Failure to follow these instructions will most likely result in an outbreak and loss of lip color where the fever blister occurs. (required)
 Yes No

I understand there may be a certain amount of discomfort associated with the procedure and that other adverse side effects may include minor and temporary bruising, redness or other discoloration and swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure may occur, however if properly cared for, is rare. (required)
 Yes No

I understand that there is a rare risk of infection, misplaced pigment, allergic reaction, swelling, fever blisters and or corneal abrasion (for eyeliner) with any cosmetic tattoo and or color change. (required)
 Yes No

I understand that implanted pigment can turn color or fade over time due to circumstances beyond the control of Barbie Conner and alter the original pigment color. (required)
 Yes No

I understand I will need to maintain the color with future applications. Sun, skin care products, lifestyle, smoking, pools and other factors play a role in pigment fading on the face. An allergic reaction can occur, most common with topicals and after care. (required)
 Yes No

I understand Vitiligo can spread with any trauma, including tattooing. (required)
 Yes No

I understand that infection and/or allergic reaction can happen with tattoos, permanent makeup. (required)
 Yes No

I understand that a patch test does not guarantee that I may not develop an allergic reaction in the future. This is not meant to scare or alarm, only to share all of the information necessary to make an informed decision. (required)
 Yes No

I understand that if I am contemplating cosmetic surgery, laser peels, laser hair removal, Botox® or collagen treatments, lip augmentation or implant surgery or other potential face altering procedure, that such procedures may adversely affect or alter my permanent makeup or traditional tattoo. It clear it is my responsibility to check with my physician or other treating technician when contemplating these procedures. Some of these potential adverse changes may not be correctable, such as pigment changes and darkening, scarring or hyper-pigmentation. (required)
 Yes No

I understand that Barbie Conner cannot guarantee the outcome of any permanent makeup procedure due to the unpredictability of the human skin. (required)
 Yes No

What, if any existing health problems do you have? (All information is confidential and will not be shared.) (required)

If I have a communicable disease such as HIV, TB or Hepatitis I have advised Barbie Conner. (required)
 Yes No

I have informed Barbie Conner of any existing health problems. (required)
 Yes No

I understand that this procedure is a form of tattooing and it is considered permanent or semi-permanent. I acknowledge that the procedure will result in a permanent or semi-permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. (required)
 Yes No

I understand that future laser treatments and/or other skin altering procedures, such as plastic surgery, implants and injections may alter and degrade my permanent makeup. I further understand that such changes are not the responsibility of Barbie Conner. (required)
 Yes No

I understand that permanent cosmetic makeup may cause MRI (Magnetic Resonance Imaging) artifacts and that there may be a warming and/or tingling sensation in the permanent cosmetic procedural area during the MRI. It is understood that I should advise my physician or x-ray technician that I do have permanent cosmetics (a tattoo) in the event an MRI of the head is prescribed. (required)
 Yes No

I understand that I will be given the opportunity to look at the permanent makeup applied before my appointment is finished and make any adjustments at that time. I understand that once my appointment is completed, I should return for a follow up visit to complete the design. I further understand that no further treatment can be performed on the same area for 4 weeks from the original service. This allows the treated area to heal properly before any further procedures are done. (required)
 Yes No

Immediately after the procedure(s) is (are) completed, the color will appear darker than when the procedure heals. Within a short period of time, during the healing process, the color will lighten. I may lose up to 60% of color after the first treatment, which is normal. This is the reason for a touch-up. I understand this as stated. (required)
 Yes No

I understand that this first touchup is included in the original service price. Subsequent touch-ups completed within one year from date of service is 60% of the cost of the original service price. After one year, touch-ups are at least half of the original service price. Example: Original price: $600. AFTER one year touchup 60% off original price = total of $240. Example: Original price: $600. AFTER one year touchup 50% off original price = total of $300. (required)
 Yes No

I understand there will be no refunds upon treatment for this elective procedure(s). I understand my payment includes ONE visit within 4 weeks of initial application. Additional visits for touchups will require further payment. Additional touchup fees vary, but will range on an individual basis from 1 to 10 years, not exceeding the original price. If I do not come to the follow up appointment in the time allowed I will forfeit my complimentary touchup, and will be charged a higher price when I do come later. It is important to come to my touchup as scheduled. (required)
 Yes No

The fee for permanent makeup services has been explained to me and has been agreed upon. I understand the total fee for services rendered is due upon completion of the initial procedure(s) and that there will be separate fees for any future modification of the design, as outlined above. (required)
 Yes No

I understand that there is a strict 48 hour cancelation policy. The deposit will be forfeited if I cancel the appointment in less than 48 hours. (required)
 Yes No

I authorize Barbie Conner to obtain pre-procedural and post-procedural photographs, and give her permission to use such photographs for publication and/or for teaching purposes, as she chooses. (required)
 Yes No

I acknowledge the digital or written receipt of written instructions advising me of the proper care of my procedures and I recognize the absolute necessity for following these instructions. (required)
 Yes No

I agree that liability is limited to the cost of the procedure performed unless it is proven that Barbie Conner was negligent in the performance of her duties. In the event of disputes that cannot be amicably resolved, Barbie Conner and myself agree to binding arbitration to resolve disputes. (required)
 Yes No

I understand that Barbie Conner will use a fresh pre-sterilized needle for all procedures. Barbie Conner follows all Occupational Safety and Health Administration (OSHA) standards on all clients. Fresh gloves are worn for all procedures! (required)
 Yes No

I understand the nature and method of the proposed permanent makeup (cosmetic tattoo) procedure, including the usual risks inherent in the procedure process, and the possibility of complications during or following its performance. (required)
 Yes No

I agree to follow aftercare instructions during the healing process. (required)
 Yes No

I understand not to get collagen after full lip procedure. I understand not to put anything other than what is advised by Barbie Conner on tattooed area for at least 10 days. I understand to only use the A&D ointment given and nothing else, and that if I use anything else I may have complications (i.e.: cold sores, blisters, color loss, blotchy color, swollen eyes, allergic reaction, etc...) I understand that there is a risk of an eye infection if the eye area is not kept clean (keep ointment out of the eye area use only in the lash line). There also is a slight risk of an abrasion on the cornea in eyeliner procedures. I understand that several touchups may be required and that all skin takes the pigment and color differently. Color needs to be checked at least once a year. I also understand there are no refunds on permanent makeup procedures. For hair simulation clients. I understand that desired results can take a few sessions. If I shade my hair a dark color, I need to keep that dark color or the shading may not look natural. i.e. Hair shading may fade, and touchups may be required. (required)
 Yes No

I have read and understand the contents of each paragraph above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I acknowledge by submitting this consent form, have been given the full opportunity to ask any and all questions about permanent makeup procedure(s) and process(es) from Barbie Conner. I understand this paper work (which includes pre and post care instructions) is part of my confidential client record for Barbie Conner. (Health Insurance Portability and Accountability Act - HIPAA) (required)

 

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