Client Information and Consent Form
Date of Birth:
Ethnic Background, please include all nationalities:
If we call you at home, do you want confidentiality?
May we call you at work?
If Yes, my work number is:
Emergency Contact, Name:
Who may we thank for referring you?
List all medications you are presently taking:
Name of drug prescribed to you, Mg. or mcg. , How many ea. day ,Why it was prescribed to you
List all medications you took in the last six months that you are no longer taking:
Do you have? (check all that apply)
If you checked any, please explain:
Are you? (check all that apply)
Do you use? (check all that apply)
Have you had? (check all that apply)
Do you practice outdoor activities? Circle all that apply
INFORMED CONSENT TO PROCEDURE
1. Are you pregnant or nursing?
2. I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed. I Agree / Understand
3. I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them. I Agree / Understand
4. Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color. I Agree / Understand
5. I understand that the color selection and color results in all procedures are not an exact science. I Agree / Understand
6. I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restalyne and I assume this responsibility. I Agree / Understand
7. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics. I Agree / Understand
8. If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure. I Agree / Understand
9. I understand that this procedure will fade and this fading can alter the original pigment color and that this determines that it is a time for a touch-up visit. I Agree / Understand
10. I realize this is an elective cosmetic procedure and is not medically necessary. I Agree / Understand
11. It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment. I Agree / Understand
12. I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent make up dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up. I Agree / Understand
13. I give my consent to Ms. Fitz Glitz and Glamour to confer with my physicians for medical information required for the safety of my procedures. I Agree / Understand
14. I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner. I Agree / Understand
15. I am aware that if an infection occurs after I have received Permanent Cosmetics to see with my primary physician or an emergency room, immediately. I Agree / Understand
I have read and understand these risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and my questions have been answered.
**Please read all questions thoroughly before signing!!
Leave this empty:
Your legal name
Signed by Tara Fitzgerald
Signed On: July 15, 2018
If you have questions about the contents of this document, you can email the document owner.
Document Name: Client Information and Consent Form
Agree & Sign