Consultation - Shusha Beauty

Consultation

Please only fill out this form if you have been instructed to do so. If this is the case, please fill it out to the best of your knowledge. We reserve the right to refuse to undertake any treatment if it is deemed unsuitable or unsafe to the client.

Client's Full Name(required)

DOB

Email Address (required)

Occupation

Phone(required)

Why do you want the treatment?

Where did you first learn about permanent cosmetics?

Please read the following carefully:

  • This treatment is a form of tattooing.
  • Retouch procedures may be required.
  • You must wait 4 to 6 weeks before a retouch treatment can be performed.
  • In rare cases the pigment may migrate under the skin.
  • Application of permanent cosmetics can be painful.
  • The pigments will fade.
  • Immediately after the treatment, the pigment can be 30 to 50% darker than the desired result.
  • There may be immediate or delayed allergic reaction to pigments. However, allergic reaction is extremely rare.
  • A negative allergy test result will not guarantee that you will not have an allergic reaction.
  • Infections can occur.
  • Allergic reactions to anaesthetics can occur.
  • There will be swelling and redness following the procedure.
  • You may experience minor bleeding.
  • Those receiving treatment for eyeliner should have someone drive them home.
  • Corneal abrasion may occur during eyeliner procedures. However, corneal abrasion is rare.
  • If you have had previous problems with cold sores/herpes and wish to receive a lip treatment, you may have a reoccurrence of cold sores following the procedure. Anti-herpes medication is available over the counter or on prescription and has been shown to prevent or minimize such outbreaks.
  • Lip treatments will appear dry and flaky for one week following the procedure.
  • Camouflage procedures are experimental in nature.
  • Camouflage procedures will need to be tested for skin colour matching.
  • There are few effective methods for pigment removal.
  • If you have a MRI scan within 3 months your permanent cosmetics procedure, it is recommended that you discuss this with your doctor.
  • Possible scarring, inconsistency of colour and loss of eyelashes may occur

Treatment to be received

Client expectations regarding the treatment and outcome

Medical Health Form

Name of Doctor

Surgery

List all the medications you have taken in the last 6 months

Have you taken any of the following in the last 2 days: Aspirin, Ibuprofen, Coumadin, Alcohol?

Have you received chemotherapy or radiation treatment in the last 12 months?
YesNo

Have you ever had an allergic reaction to any of the following (indicate Y / N)

  • Adrenaline YesNo
  • Anaesthetics YesNo
  • Crayons YesNo
  • Drugs YesNo
  • Foods YesNo
  • Glycerine YesNo
  • Hair dyes YesNo
  • Lanolin YesNo
  • Latex Rubber YesNo
  • Lidocaine YesNo
  • Medication YesNo
  • Metals YesNo
  • Nuts YesNo
  • Paints YesNo

If you have indicated Yes to any of the above, please specify the product and nature of the reaction

If you have any other allergies, please list them here and provide details

Please indicate if you have experienced, or currently have, any of the following medical conditions

  • Healing Problems YesNo
  • Heart Murmur YesNo
  • Hepatitis YesNo
  • High Blood Pressure YesNo
  • HIV YesNo
  • Hypertrophic Scars YesNo
  • Keloid Scars YesNo
  • Kidney Disease YesNo
  • Liver Disease YesNo
  • Low Blood Pressure YesNo
  • Mitral Valve Prolapse YesNo
  • Palpitations YesNo
  • Pregnant YesNo
  • Prolonged Bleeding YesNo
  • Prosthetic Hip or Joint YesNo
  • Recent Hair Loss YesNo
  • Rheumatic Fever YesNo
  • Scar Easily YesNo
  • Sensitivity to Cosmetics YesNo
  • Stomach Ulcers YesNo
  • Stroke YesNo
  • Thyroid Disturbances YesNo
  • Trichotillomania YesNo
  • Tuberculosis YesNo
  • Tumours, Growths or Cysts YesNo
  • Watery Eyes YesNo

Please indicate whether you have had any of the following

  • Acutance (within last 6 months) YesNo
  • Botox injections YesNo
  • Chemical or laser peel (within last 6 months) YesNo
  • Collagen Injections YesNo
  • Contact Lenses YesNo
  • AHA preparations (within last 2 weeks) YesNo
  • Cortisone (within last 6 months) YesNo
  • Eyelash/ eyebrow tint YesNo
  • Eyelid Surgery YesNo
  • Fat Transfer Injections YesNo
  • Gore-Tex Implants/Silicone Injections YesNo
  • Other Tattoos YesNo
  • Pacemaker YesNo
  • Retin-A within 6 months YesNo
  • Use of Sun bed YesNo

If you have indicated Yes to any of the above, please provide some details so that you technician may assess the relevance of this for your proposed permanent cosmetics treatment

I have read and fully understood the above information. ?

General consent and procedure permit

  • I hereby authorise Azar Shusha Griffin (technician) of Shusha Beauty (salon) to perform upon myself the following procedure(s)
    Cosmetic Tattoo Brows ?Cosmetic Tattoo Lips ?Cosmetic Tattoo Eyeliner ?

  • If any unforeseen condition arises in the course of this procedure(s), calling in her judgement in addition to, or different from those now contemplated, I further request and authorise him/her to do whatever she deems advisable and necessary in the circumstances.
  • I fully understand, as with all such procedures that this is not a science but rather an art. Depending on the procedure(s) selected, I accept responsibility for determining the colour, shape and position of eyebrows, eyeliner, lip-liner / lip shading, beauty mark, tattoo or other as agreed during the course of my consultation.
  • It is understood that a sensitivity test is available at least 24 hours prior to procedure for pigments and topical anaesthetics. The purpose of the test is to detect allergic or other reaction. I understand that if I do not wait the full 24 hours after the skin test, for treatment that it is at my own risk if any allergy occurs.
  • I fully understand and accept that non-toxic pigments are used during the procedure(s) and that the cosmetic enhancement achieved may fade in between one to three years. Even though the colour has faded the pigment will stay in the skin indefinitely.
  • I have been informed that the highest standard hygiene is met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit.
  • I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I need to return for a retouch procedure.
  • I understand that a retouch procedure will be performed one to three months after the initial procedure. I understand that after a three month period, I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties.
  • The result of the procedure is determined by the following:

    1. Medication
    2. Skin Characteristics (dry, oily, sun-damaged and thickness)
    3. Natural skin undertones (blending with chosen pigment)
    4. Personal pH balance of skin, which changes from visit to visit
    5. Alcohol intake and smoking
    6. Post-operative care treatment
  • Upon completion of the procedure there may be swelling and redness of the skin, which will subside in between one to four days. In some cases bruising can occur. Clients may resume normal activities immediately following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. Clients can however, be assured that the procedure, even after only one treatment, appears acceptable and that they can appear in public without additional makeup on the affected area.
  • I have been advised that the true colour will be seen one month after each procedure, and that the pigment may vary in colour according to skin tones, skin type, age and skin conditions. I understand that some skins except pigment more readily than others and no guarantee to an exact effect or colour can be given.
  • I am aware that the lip procedures may stimulate any dormant virus such as herpes (cold sores). I am informed that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment.
  • To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I do not have a heart condition. I do not have epilepsy. I have not had hepatitis within the last year. I am not haemophiliac. I do not have HIV. I am not under the influence of drugs or alcohol.
  • I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician ?
  • Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by Azar Shusha Griffin (technician)
  • For the purpose of documentation, I also consent to the taking of ?before? and ?after? photographs of said procedure(s)
  • I certify that I have read, and have had explained to me, and fully understand the above consent and procedure permit; that the explanations therein referred to were made, and I accept full responsibility for these and or other complications which may arise or result during or following the permanent cosmetic / tattoo procedure(s) which is / are to be performed at my request according to this consent and procedure permit, that all blanks or statements requiring insertion or completion were filled in before I signed. I have read and understood the above information.

Client Name

Date

Signature