Client Personal Record & Medical History Printable version(click here)
Phone： (H) __________________________ (W/C) __________________________________
Date of Birth： _______________________________________ Sex：________________________
MEDICAL HISTORY (please mark Y for “yes” or N for “no”)
Allergies ________ Keloid Scars_______ Diabetes _______ Cold Sores/Shingles_______
Iron Deficiency Anemia______ Hemophilia ______ Hypoglycemia______ Aids (Hiv)______
Asthma_________ Pregnancy _________ Heart Problem_______ Cancer________
Hepatitis /Jaundice_______ High Blood Pressure________ Current Medication_______________
Accutane________ Blood Thinner________ Constipation ______ Skin Disorder/s____________
Regular Periods________ Menopause______ Contact Lenses______ Laser Treatment________
Botox _____ If yes, when did you last have Botox?_________ Are you planning more Botox? _______
Fillers _______ Do you plan to continue with Fillers? _______
Are you planning on one day having a surgical brow/face lift? _________ Other _____________________
Do you have old permanent makeup ?______Area__________________When was it done______________
I acknowledge that any information contributed by me is true, to the best of my knowledge and that the present condition of the area that has been treated or will be treated is stated on this record. I fully understand that Iris Beauty Solution only provides beauty services; there is no medical treatment involved.
I realize that with any beauty service there may be certain risks which must be understood. I will be fully responsible for any and all results which may arise from these beauty services. I do hereby agree to V. Kuzmin and Iris Beauty Solution, their employees and agents, free from any and all claims or suits for damage, for injuries or complications resulting from any beauty service provided by Iris Beauty Solution.
The nature and purpose of the beauty services, the risks involved and the possibility of complications have been fully explained to me. I understand that no guarantee or assurance has been given by anyone as to the results that may be obtained.
By signing below I acknowledge that I have read and understand the above and all of my questions have been answered and that I consent to have the above beauty services.
Iris Beauty Solution DISCLOSURE & RELEASE FORM FOR IMPLANTATION OF PIGMENT FOR: EYELINER, EYEBROWS, LIPS, RECOLORATION AND CAMOUFLAGE
Iris Beauty Solution appreciates your patronage and interest in new and improved techniques of Semi-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. This disclosure is not meant to frighten you. It is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure.
Please read the statements below, putting your initials before each one, to indicate:
I understand the following completely:
_____ That no warranty or guarantee has been made to me as a result of this permanent
Makeup / camouflage / correction procedure, and that the final result cannot be guaranteed.
_____ I realize that there is potential for discomfort during the procedure and during the healing process as well as a possibility of bleeding, swelling, and allergic reactions to the dye.
_____ That tattooing is considered permanent, however, it will fade with time.
_____ That a tattoo can only be removed with a surgical procedure, and that any effective
removal may leave permanent scarring or disfigurement.
_____ That misplacement of the dye can occur, under rare circumstances, requiring excision of
the misplaced dye. In rare cases, there may be permanent loss of eyelashes.
_____ That hair stroke technique can not be used on top of old permanent makeup tattoo. Old ink must be removed completely before hair stroke can be implanted into the skin.
_____ I understand that healing process is different for every person. Pigment loss or color change is normally happened in most of the cases during first week. I have to stay calm, not panic and return for touchup session not earlier then 4 to 6 weeks after initial session (when skin is completely healed). Disposable material’s fee for Touchups session due to loss of pigment in the healing process during 3 month after first appointment is minimum $75 every visit( in some cases 2-3 visits are required).
_____ I have been given the opportunity to ask questions about the procedure, the risks, and the hazards involved.
_____ I believe that I have sufficient information to give this informed consent.
CLIENT ACKNOWLEDGMENT AND RESPONSIBILITY TO INFORM THE TECHNICIAN
CLIENT further agrees to indemnify and hold harmless Iris Beauty Solution, its governing officers, consultants, employees, agents, and subsidiaries, from any claim of liability, losses, damages, or any expenses whatsoever as a result of any claims, demands, damages, costs or judgments 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 Iris Beauty Solution and its client in connection with permanent makeup procedures.
The CLIENT has been given a copy of this Agreement prior to the 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.
_____ I understand that I must inform my technician of all medications being taken by me, even though I have written it on the l Medical History . For example,pain control medication such as aspirin may cause the blood to thin, and excessive bleeding may occur.
_____ I 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.
_____ I have no known allergies to dye, nickel, any topical anesthetics.
______I understand that taking Before and After pictures is a condition of such procedures. I hereby forever release and discharge Iris Beauty Solution from any and all claims, action and demands arising out of use of said photographs I for website.
_____ I have also read and understand Aftercare Treatment Instructions and recommendations, and I understand my responsibility to follow them to ensure proper healing of the treated area .
._____ I release Iris Beauty Solution and its representatives and subsidiaries of all claims for injury, seen or unseen that may occur as a result of this procedure.
I fully understand the questions, terms, and conditions of this Disclosure and Release Agreement, and all have been explained to me in my native language. I accept to waive all my rights for any claim against the technicians / /Iris Beauty Solution for any reasons may involve whatsoever.
I certify that this Disclosure and Release Agreement was completed by me and that all entries in it and information are true and complete to the best of my knowledge.
Client’s Printed Name ___________________________________
Client’s Signature _____________________________________ Date _____________