PERMANENT MAKEUP CONSULTATION FORM

To avoid unforeseen complications, please answer the following questions:

Name *
Name
Address *
Address
Phone *
Phone
Birthdate *
Birthdate
Are you now or have you been under a physician’s care within the last two years? *
Do you take medications?
Do you have any allergies such as food, pollen?
Are you sensitive to any drugs such as penicillin, aspirin?
Do you bleed excessively after cut, wound or surgery?
Are you subject to fainting, dizziness, or nervous disorders?
Have you ever had any breathing difficulty such as asthma, emphysema, chronic cough, pneumonia, TB or lung disorders?
Are you pregnant?
Do you wear contact lenses?
Have you ever had any of the following?
Are you under the age of 18? *
(If you answer yes, please have your legal guardian type their name below)
(Please type out your name and that will serve as a signature)
Have you had any aspirin or blood thinning products within the last 7 days? *
Have you had any mood-altering drugs within the last 8 hours? *
Are you sensitive to latex? *
Have you had a chemical or laser peel? *
If you answered yes to have a chemical or laser peel, please input the date of the peel:
If you answered yes to have a chemical or laser peel, please input the date of the peel:
Do you have problems healing? *
Have you had any previous problems with tattoos, or has your physician advised you not to have a tattoo at this time? *
Are you currently undergoing radiation or chemotherapy? *
Are you currently using Retin-A or Alpha Hydroxy skin care products? *
Do you wear contact lenses? *
(If yes, they must be removed before eyeliner procedure and should not be replaced until the next day)
Are you allergic to any metals? *
Are you taking any anti-inflammatory medication or steroids? *
Are you suffering from withdrawal from caffeine products? *
Are you allergic to topical antibiotic preparations or desensitizers? *
(i.e. polysporin, bacitracin, neosporin or “caine” family of drugs or petroleum)
Do you have a history of any skin diseases or remarkable skin sensitivities? *
Are you currently taking Vitamin A and/or E in any form? *
Are you pregnant or nursing? *
Are you required to take antibiotics during dental or invasive medical procedures? *
Please check the following:

POST PROCEDURE INFORMATION

OVERALL

Day 1

Swollen, like you’ve been crying, with a heavier eye makeup look

Day 2

Swollen, usually for only a few hours after waking up, with a heavier eye makeup look continuing

Day 3

Swelling decreases with a tint feeling. The pigment begins to lift away from the skin.

Day 4

There is a slight “pinching” feeling. Some itching is normal as the skin begins to flake. DO NOT PICK AT IT.

Day 5

Blinking movement of the eye usually removes all pigment by this day. Color is somewhat grayish and will take a few more days to clarify to full color.

EYEBROWS

Day 1 & 2

The eyebrows are approximately 20 to 25% darker and bolder in width than they will be when healed. Your skin is red under the pigment, which causes the color of the pigment to appear darker. There is some swelling, although difficult to see due to the thickness of the skin in the eyebrow area. This will subside. Exfoliation, which begins in a few days, will cause excess pigment surrounding the eyebrow procedure to flake away and a narrower appearance of your eyebrows. Don’t be concerned that your eyebrows initially appear darker and heavier in size than you desire. This is all part of the process. 

Day 3

Eyebrows start to itch and will appear a bit thicker in texture. Exfoliation begins 

Day 4

The skin begins to flake, peeling from the outside edges first. 

Day 5

Color finishes flaking off and appears softer and grayer for a few days until color clarifies.

LIPS

Day 1

Swelling, tender, heavy thick lipstick look with an orange/brick color effect.

Day 2

Slight swelling, intense color

Day 3

Less swelling, thicker texture, sore, hot feeling before exfoliation with an orange color effect

Day 4

Exfoliation begins, very chapped lips. Sloughing off/peeling of dry skin w/pigment

Day 5

Very chapped, almost finished with first chapping stage. Appears like most of color has sloughed off 

Day 6

A soft, color begins to appear

Day 7-13

Lip color disappears and the “frosty” (2Nd chapping stage) begins as a whitish/gray haze on the lips.

Day 14

Color “blooms” from within more and more each day as the new skin heals completely 

Day 21

Healing complete; the color you see is the color you have. Your lips will remain a bit dry for a month or two. Use a good balm and they will return to normal, but with full color.

Permanent makeup procedures are affected by the canvas (your skin) that they are performed on. If your skin is sun damaged (even from tanning beds), thick and uneven in texture, and/or excessively dry or oily, the result cannot be expected to be perfect after the initial procedure. Scars on the lips from fever blisters cause pigment removal. Lifestyle, medications, smoking, metabolism, facial surgery, and age of skin, all contribute to fading. Touch ups are needed 30 days after your initial procedure to ensure the best results and to keep your permanent makeup looking the best. Your procedure maintenance, as outlined in your pre/post procedure directions, is a very important.

Practitioner makes no attempt to, or claim to, practice medicine. Some individuals will have complications related to permanent makeup application. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. If you are healthy and there are no visible reasons restricting you from receiving a tattoo, you must approve of the design and color before the appointment.

The term, permanent cosmetics, is actually Extended Wear Cosmetics and fade in varying degree depending on the individual. Some clients may need a maintenance application sooner than others.

Due to varying degrees of difficulty of applications associated with lip/skin texture, scarring or wrinkles around the lip lines from cold sores, age, laser treatments, medications, smoking, sun exposure, and glycolic acid creams- we cannot guarantee “perfect” results in two weeks.

Therefore, if irregularities in lip color develop from the above-mentioned conditions, additional procedures may be necessary.


MAKEUP

Client has retained the services of Virago Skin and Body, for the application of permanent cosmetics, and has advised that this procedure involves several appointments.

Client has been fully advised and understands that this procedure will involve some discomfort and that there is a risk that Client’s skin type will not accept color pigmentation. 

Virago Skin and Body will advise clients how and where the application the application should be done in his/her professional estimations; however, if the client desires a different application than that advised by Rosina’s, the results of such different application are solely at client’s risk.

Client hereby releases Virago Skin and Body from all actions, causes of action, suits, claims and demands for damages and injuries which materials used and furnished to client in connection with the application of products furnished to client or applied to any part of clients face or body by Virago Skin and Body. 

Client represents that he/she has no history of occurrences of adverse skin reactions, whether relating to the use of cosmetic products of otherwise and assumes all risk of injury which may be sustained as the result of such application whether caused by the materials and/or products used or the manner of services rendered by Virago Skin and Body.

Client understands and acknowledges that certain cosmetic products contain reactive chemicals that may induce allergic reactions in some persons and hereby releases Rosina’s from any and all claims that may arise from any such reaction.

Client realizes in executing this release that he/she is indemnifying and holding Rosina’s harmless from any and all possible, actual or claimed conduct, either by way of act of omission by them, or any of them, whether in formulation of manufacture or application of the products used. 

Client affirms that he/she is eighteen years of age or older and has carefully read the above and thoroughly understands its terms and meaning.

Client knows of no reason why he/she is not free and competent to execute this release.

By filling your name in here, you have officially signed this document.*

SIGNATURE
Name *
Name