CLIENT'S INTAKE FORMS

Timeless Beauty, Naturally Refined

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Client's name (Please provide the same first & last name on your ID) *

First

Last

Phone Number *

Email *

Address (Please provide the same address on your ID) *

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City

State

Zip Code

Country

PRECAUTIONARY COVID-19 LIABILITY RELEASE FORM

Due to the 2019-2020 outbreak of the novel coronavirus, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices.

Please complete the following and sign below.

SYMPTOMS OF COVID-19 INCLUDE FEVER, FATIGUE, DRY COUGH, DIFFICULTY BREATHING, ETC.

Please check the box to agree *

I understand the above symptoms and affirm that I, as well as household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all household members, have not been DIAGNOSED with COVID-19 within the last 30 days. I affirm that I, as well as all household members, have not knowingly been EXPOSED to anyone diagnosed with COVID-19 within the last 30 days. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days. I understand that this studio and their staff cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

By signing below, I agree to each above statement and remove this studio and their staff from any and all liability for the unintentional exposure or harm due to COVID-19.

Client's Signature ( Please leave this section blank. Your technician will preview your informations and have you sign at your appointment) *

Your Technician agrees that she abides by these same standards and affirms the same. She also affirms that she has improved and expanded her sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

Technician's Signature *

CLIENT PERSONAL RECORD

Please list any current medications: *

MEDICAL HISTORY FORM

CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETIC PROCEDURE

The Cosmetic Tattoo / Permanent Make-up Technician, herein designated Technician, who will be performing the requested Cosmetic Tattoo / Permanent Make-up procedure(s), and the undersigned client, herein designated Client, who will receive the Cosmetic Tattoo / Permanent Make-up procedure(s) are subject to the terms and conditions specified herein:

This agreement to have a Cosmetic Tattoo / Permanent Make-up procedure is entered into by the Technician and Client

AGREEMENT

ACKNOWLEDGEMENT OF COMPLICATIONS ASSOCIATED WITH PERMANENT MAKE-UP *

1. The Client has been informed by the Technician of possible risks, dangers, and complications associated with having a Permanent Make-up facial tattoo procedure performed. The Client acknowledges that these dangers may include: eye injury, allergies to any materials used in the process, fever-blisters and cold sores, swelling, bruising (although rare), temporary minor bleeding, redness, risk of spreading, fading, and fanning of pigment, and various other possible unintended or negative results of the procedure, some or all of which may not be desirable to the Client. 2. Having been completely advised on all inherent risks, dangers, and complications associated with Permanent Make-up facial tattoo procedures, the Client hereby voluntarily assumes all risk of any possible negative result ensuing from the Cosmetic Tattoo / Permanent Make- up procedures which are to be performed.

ALLERGY PATCH TEST/WAIVER *

The Client agrees to take a allergy patch test prior to the Permanent Make-up facial tattoo procedure (the expense of which is to be borne by the Client) in order to determine allergic or other reaction to the applied materials (such as pigments, anesthetics, and other items typically used in the procedure(s)) and to detect fading or changes in the applied pigments which may occur on application, or to waive such at this time, acknowledging that this waiver may increase the potential of occurrence of such allergic and other reactions to the materials which are used in the procedure. Initial below to waive the allergy test.

RESULTS *

The client agrees to accept full responsibility for the color, shape, and thickness of each and every procedure executed by the Technician, to include but not limited to eyebrow Microblading or Powder Brow / SoftTap technique, or any other Cosmetic Tattoo / Permanent Make- up procedure.

RECEIPT OF PRE-PROCEDURE AND POST-PROCEDURE INFORMATION *

The Client acknowledges receipt of pre-procedure information and post-procedure (aftercare) instructions from the Technician, and agrees that they have read them, have been advised of them, understand them, and agree to adhere to them in order to help ensure satisfactory results from the procedure(s) and help prevent secondary infection. The Client acknowledges that all final adjustments and detail work will be done in the second session, and will schedule a follow-up session with the Technician within 4- 6 weeks of the procedure(s).

CONSENT OF PERMANENT MAKE-UP PROCEDURE *

The Client fully, and voluntarily, consents to have the Technician perform the Cosmetic Tattoo / Permanent Make-up procedure(s), and is fully aware and informed of all and any inherent risks, dangers, and complications associated with having Permanent Make-up facial tattoo procedures performed. The Client has had any questions or concerns which he/she has expressed satisfactorily answered or resolved by the Technician.

RELEASE OF CLAIMS *

The Client, realizing that Cosmetic Tattoo / Permanent Make-up procedures of the type of those specified in this agreement are fraught with risks and dangers which cannot be eliminated from the process regardless of the precautions and safeguards which are undertaken, hereby agrees that the client releases the Technician from any and all claims, damages, and liability of all types relating to the performance of the specified procedure(s), including any costs of medical care or assistance required by the Client as a result of the procedure(s) performed, which shall include any post-operative care, repair or reconstruction which the Client may require or desire. This release agreement by the client shall also extend to the proprietors, officers, agents, and employees of any business Technician that is employed by or associated with performing the Cosmetic Tattoo / Permanent Make-up procedure(s).

IN WITNESS HEREOF, Client and Technician do hereby give their assent to the terms of this Agreement on the date entered.

Client's Signature ( Please leave this section blank. Your technician will preview your informations and have you sign at your appointment) *

Technician's Signature *

DISCLOSURE & RELEASE FORM FOR PERMANENT MAKEUP SERVICES

ADVANCED INK / THUY LAM appreciates your interest in the new and improved techniques of Cosmetic Tattoo / Permanent Makeup. You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved.

CLIENT DISCLOSURE

CLIENT ACKNOWLEDGEMENT AND RESPONSIBILITY TO INFORM TECHNICIAN

CLIENT further agrees to indenify and hold harmless THUY LAM, its governing officer from any claim of liability, losses, damages, or any expenses whatsoever as a result of any claims, demands, damages, costs, or judgements including, but not limited to, claims based on negligence against it, that may arise in connection with the services performed by an independently contracted technician.
This agreement is intended to be an addendum to any previous conditions, releases, or hold harmless agreements, in written form, verbal, or manually communicated between THUY LAM and its client in connection with Cosmetic Tattoo / Permanent Makeup procedures. The CLIENT has been given a copy of this agreement prior to the Cosmetic Tattoo / Permanent Makeup procedures being performed and has been given the opportunity to attain reasonable understanding of this agreement, including the opportunity to ask questions, either by written, verbal, or manual communication prior to the signing of this document.
As a client, you have a responsibility to inform the technician of all possible concerns. Please read the following and initial before each statement.

Choose Any *

I understand that I must inform the technician of all medications being taken by me, even though I have it written on my Medical History Form. For example, pain control medicine such as aspirin may cause the blood too thin, and excessive bleeding may occur. understand that it is my responsibility to advise the technician of any concerns I may have before they begin the procedure, even though I may have written it down on the form. I am free from drug and alcohol use or any other substances. I am not pregnant or breastfeeding. I have no known allergies to dye, nickel, or any topical anesthetics. I understand that taking before and after pictures is a condition of such procedures. I hereby forever release and discharge ADVANCED INK / THUY LAM from any and all claims, actions, and demands arising out of use of said photographs for website and social media. I have read and understand Aftercare Treatment Instructions and recommendations, and I understand my responsibility to follow them to ensure proper healing of treated area. I release ADVANCED INK / THUY LAM and its representatives and subsidiaries of all claims for injury, seen or unseen that may result as a result of this procedure.

LIPS BLUSH , BROWS , EYELINERS CLIENT CONSENT FORM

Procedure Desired: *

Eyebrows Tattoo Lips Tattoo Eyeliners Tattoo Beauty Marks Tattoo

Have you ever had a cold sore? *

Yes No

If yes, you must contact your physician for a prescription of an antibiotic that prevents cold sores.

I have read the above information regarding the antibiotic and understand its use is mandatory if I desire Lips Tattoo Procedures

Client's Signature ( Please leave this section blank. Your technician will preview your informations and have you sign at your appointment) *

Are you currently under the care of a physician? *

Yes No

If so, why? *

Physicians Name *

Do you take antibiotics when going to the dentist? *

Yes No

If so, why? *

If other, explain: *

Are you presently taking any medication that thins the blood? *

Yes No

Are you taking any medications? *

Yes No

If yes, what medications? *

Are you pregnant or nursing? *

Yes No

Do you wear contact lenses? *

Yes No

Client's Signature ( Please leave this section blank. Your technician will preview your informations and have you sign at your appointment) *

PRE-EXISTING CONDITIONS WHICH MAY AFFECT YOUR SUITABILITY FOR THE DESIRED

To help minimize any risks, which might be a part of the procedure(s), the Client should answer the following questions truthfully and to the best of their ability, in order to assist the specialist in ensuring that the Client is a suitable candidate for the procedure(s) requested. The client acknowledges that any incomplete or inaccurate answers given to these questions may increase the possibility of complications and unwanted results from the procedure(s), and as such, confirms that the answers given are true and accurate.

In the event that additional space is required, use the back of this form or additional paper; if the explanation is difficult to write briefly or concisely, please discuss it directly with the Technician.

THE TECHNICIAN WILL NOT PERFORM ANY PERMANENT MAKE-UP PROCEDURE ON A MINOR.

POSSIBLE RISKS, HAZARDS OR COMPLICATIONS

   •   Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.
   •   Infection: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands with gloves should touch the areas.
   •   Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your follow-up appointment will likely correct any uneven appearances.
   •   Asymmetry: Every effort will be made to avoid asymmetry, but our faces are not symmetrical, so adjustments may be needed during the follow-up session to correct any unevenness.
   •   Excessive swelling: Some people swell more than others. Swelling typically disappears within 1-5 days. Some people don’t swell at all.
   •   Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, Epinephrine in a cream or gel form are typically used. If you are allergic to any of these, please inform me now.
   •   MRI: Because pigments used in Cosmetic Tattoo / Permanent Make-up procedures may contain small traces of nickel, a low-level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any Cosmetic Tattoo / Permanent Make-up.
   •   Allergic Reaction: There is a small possibility of an allergic reaction. You may take a patch test to determine this.
   •   Medical Attention: If you see any abnormal infection or swelling, please call your doctor for medical help!

Client's Signature ( Please leave this section blank. Your technician will preview your informations and have you sign at your appointment) *

CONSENT AND RELEASE AGREEMENT

All Cosmetic Tattoo / Permanent Make-up use the process of inserting ink into the epidermis layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Health department regulations are STRICTLY adhered to. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed. Sometimes a 3rd session is necessary. Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7-10 days the color will fade 10-20%, soften and look more natural. Please note that color may fade faster on oily skin or skin with large pores.

PHOTOGRAPHY RELEASE CONSENT

ADVANCED INK / THUY LAM would like your permission to use these photos for advertising. For example, in portfolios, online and in print ads, etc. They are also needed for insurance purposes. Your consent is necessary regarding this.
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. All information is true and accurate to my knowledge: lying about anything may result in risk or hazard to you. ADVANCED INK / THUY LAM is not liable for any falsification on these records. I acknowledge that I have reviewed and approved the material given to me, and ADVANCED INK / THUY LAM as my technician to perform on my body, the PMU procedure desired today.

Client's Signature ( Please leave this section blank. Your technician will preview your informations and have you sign at your appointment) *

STATEMENT OF CONSENT & RECITALS FORM

CONSENT & RELEASE FORM

Check box to agree *

I am over the age of 18, am not under the influence of drugs or alcohol, and desire to have the Cosmetic Tattoo / Permanent Make-up service(s) performed. The general nature of Cosmetic Tattoo / Permanent Make-up, as well as the specific procedure(s) to be performed, has been explained to me. I have been informed of the nature, risks, and possible complications and consequences of Cosmetic Tattoo / Permanent Make-up. I understand the Cosmetic Tattoo / Permanent Make-up procedure carries with it known and unknown complications and consequences associated with this type of Cosmetic Tattoo / Permanent Make-up procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning, or fading of pigments. 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 Cosmetic Tattoo / Permanent Make-up procedure and accept the permanence of the procedure, as well as the possible complications and consequences of the said procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each individual’s reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent. 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 Cosmetic Tattoo / Permanent Make-up. 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. I consent to have the treatment site(s) photographed before, during, and after treatment and that these photographs may be published on our website or displayed in print or electronic media. Identifying information will be concealed.

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