EYELASH CANADA INC. CONSENT TO MICROPIGMENTATION PROCEDURE
FULL NAME *
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ADDRESS *
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PHONE # *
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E-MAIL *
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CITY *
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Birth Date *
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DD
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Emergency contact, name and phone number
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All sessions are video taped
Upper Eyeliner / Lower Eyeliner / Eyebrows / Full Lip Colour / Lip Liner / Scalp / Cheek Colour / Beauty Mark / Nipple / Areola / Scar Camouflage / Other *
Your answer
If “other” please explain
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TOUCHUPS ARE NOT FREE Cost $75 between 6 to 12 weeks *
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Touch up: Half our regular price between 3 Months and 2 yr. After 2 yr redo tattoo cost full price ______
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Colors used *
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Preparing before EYELINER procedure. Bring dark sun glasses, Do not wear contact lenses for 48 hrs after, Do not drive after procedure, Your eyes may be swollen for 2 to 7 days, Your vision may be blurry for 1 to 2 days, Your eyes could feel irritated for 2 days due to continual wiping during the procedure. This may feel like you have a grain of salt in your eye this feeling may last 1 to 3 days. Please note EYEBROWS do not have these types of feelings. *
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I am over the age of 18, and desire to receive the indicated semi-permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure has been explained to me. (initial)_____ *
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I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the skin pigmentation procedure(s) and accept the permanence of the procedure as well as the possible complications like fading and slight colour change of the mentioned procedure(s). (initial)_____ *
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I have received pre- and post procedure instructions and I will follow such instructions. I understand that my failure to do so may jeopardize my chances for a successful end result. (initial)_____ *
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I understand that if I am contemplating cosmetic surgery or treatments such as laser peels, laser hair removal, botox, collagen treat¬ments, lip augmentation, implant surgery or any other face altering procedure, it is possible that those procedures may alter the appearance of my micropigmentation. (initial)_____ *
Your answer
Are you currently under the care of a physician? *
If yes, it is your responsibility to discuss with your physician or other treating technician that you are contemplating this procedure. (initial)_____ *
Your answer
Have you ever had a cold sore? *
If yes, I will consult with and strictly follow my doctor’s instructions before contemplating any permanent cosmetic procedure around my lips. Your physician may prescribe acyclovir capsules for preventing cold sores.
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Do you suffer from: *
Required
If other, please explain
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Do you take antibiotics before you go to the dentist?
Are you presently taking any medication that thins the blood?
Are you presently taking other medications?
Are you pregnant or nursing?
Are you allergic to Lidocaine?
We will be using Lidocaine as local Anesthetic during this procedure
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