Client

Qestionnaire
and Consent

Personal Information

NAME

ADDRESS

PHONE #

EMAIL

Medical History

Please answer the following questions to the best of your ability:

Yes No

Do you wear contact lenses? (If yes, they must be removed during eyeliner treatment)

Have you tested positive for HIV or Hepatitis?

Do you have insulin depentdant Diabetes?

Do you have autoimmune conditions?

Have you had a joint replacement?

Have you had a valve replacement?

Do you have a pacemaker or Magnetic Donut?

Have you recently had a shingles vaccine?

Have you recently undergone surgery around the eye area?

 Have you recently undergone cataract surgery?

Do you have glaucoma?

Do you have any allergies to anesthetics?

Do you have any allergies?

Does your skin swell easily?

Do you bruise easily?

Do you have any body or cosmetic tattoos?

Are you pregnant?

Are you nursing?

Do you have any heart conditions?

Are you currently on any blood thinning medication?

Have you ever had a fever blister, cold sore, Shingles, or canker sore?

Do you have a history of keloid scarring?

Are you taking any immunosuppressant or anti-inflammatory medication or sterroids?

Are you able to take over-the-counter antihistamines?

Are you allergic to topical antibiotic preparations? (i.e. Polysporin, Bacitracyn)

Do you use Retin A or Hydroxyl (Glycolic) Acid?

Do you use Latisse for eyelash/ eyebrow growth?

Do you suffer from any notable conditions not mentioned above?

If you answered yes to any of the questions above, please provide more information here:

________________________________________________________________________________________________
________________________________________________________________________________________________

CONTRAINDICATIONS

In medicine, a contraindication (of a condition or circumstance such as a major or minor health condition)
suggests or indicates that (a particular technique or drug) should not be used in the case in question.
I have been made aware that if I do have a pre-existing consition that has been approved by an Ink by Nada
employee that results can be impacted in shape, colour, and retainment. I also know that I may be asked at any
given time to provide a clearance note from my doctor for the following medical conditions:

Diabetes (Type 1 and 2)

Auto-immune disease
Thyroid/ Graves disease
Cancer (if in remission within the last two years a docto's note must be provided)

POSSIBLE RISKS & HAZARDS/ COMPLICATIONS

On average, permanent makeup appointments can last between 2/12 - 4 hours+ depending on the service
however, We CANNOT guarantee this for all clients. It's important that you understand that satisfactory results
of this procedure depend 50% on the artist, and 50% is up to your skin and how you care for your tattoo after
you leave our studio.

Allergic reaction - Allergic reactions can occur from any anesthetics used during the procedure. If you do suffer
from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show
through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.

Pain & Numbness - We cannot accept responsibility if the area to be treated does not respond to the numbing
cream. Each individual is different according to skin type. Some clients report the area to be completely numb,
while others may experience some discomfort.
Ink by Nada does offer numbing cream/gel for most permanent makeup procedures at some point in the
session. The products are formulated to be perfectly safe and can be purchased over the counter from any
pharmacy/chemist (Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine cream or gel form typically
used). As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some
redness/swelling that can last 1-4 days. You should always follow your post procedure advice and after care for
the best results.

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

MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may
be required if you need to be scanned by an MRI machine. You must inform your MRI Technician of any tattoos
or permanent cosmetics.

POSSIBLE INFECTIONS
Although it's important to note that infections during the a cosmetic tattooing process are VERY RARE (about
1-3% or 1-3 in 100 people), it's important to understand what risks it can include and how to treat it if you
suspect it.

All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after
use. Cross contamination guidelines are strictly adhered to. If at any point the area treated becomes red, itchy,
oozing, overly inflamed these are possible signs of infection, you must contact a doctor or go to the nearest
medical facility immediately.

It is highly crucial that you follow the aftercare process to a T as there can be a small risk (around 1-3%) that
you may experience an infection if not taken with proper care. In mild cases, infections can be treated with over
the counter antibiotics that can be topically placed on your skin. In extreme, serious cases, you may need to see
a doctor and recieve a perscibed antibotic that you cannot recieve over the counter. The biggest risk in
developing a deep infection to the skin can turn into a condition known as "Cellulitis".
Cellulities is an infection of the inner layer of the skin that can spread if not treated appropriately. Other
conditons such as Nickel reactions and rashes can occur if the client is allergic to the pigment that is placed on
their skin. (Please note, Ink by Nada Pigments are water based and do not include Nickel but this is important
to know in case you ever decide to receive pmu services from another establishment.) If you suspect that you
have an infection, please contact Nada immediately.
Early stage infection symptoms:
• Odour coming from the treatment area
• Discharge that may be a greenish/brown color
• Resness around the procedure area but not extending beyond it
• Tenderness when touched *with the exception of your aftercare products, please avoid touching the treated
area after the procedure!

Most of these symptoms can be treated as long as you catch it early. Please consult a medical professional to see
if you should consider these tips if you have an early infection:

• Consider using an antibiotic ointment like Bacitracin. Bacitracin will treat the most common skin
pathogens such as staph and strep (even MRSA) and does not include ointments that can irritate the skin.
• Avoid using triple antibiotic ointment like neosporin which contains neomycin that approximately 1 in 10
people react to with a rash (that's a LOT of people).
• Avoid covering up the treated area with creams and gels such as Vaseline or other emollients which can trap
in heat and keep an infection in the wound (remember bacteria dies in the presence of oxygen)
• Consider using a cold pack to reduce swelling and heat, this can also help alleviate some of the
pain/tenderness
• Keep the area clean! Avoid using makeup or other topical agents (besides the antibiotic) on your skin/wound
If the infection continues to develop and you begin to experience; extreme swelling/tenderness/pain or
fever/chills (signs suggest you have a systemic infection) please contact your doctor ASAP. These are early
signs that you may be developing facial cellulitis and may need oral or IV antibotics.

CARE & MAINTENANCE

Aftercare is a crucial element to follow to ensure proper healing and colour retention. Results vary for all
individuals and we cannot guarantee your results. Please do not use other products or follow other artist's
aftercare instructions during your healing process.
Please follow the aftercare directed for the appropriate service. This information will be given to you by your
artist.

I agree to follow the care and maintenance instructions provided by the artist for the care of the procedure area
following the procedure, and that if any follow up care is required due to my own mistake or negligence, or
failure to follow these instructions, this will be at my own expense and risk. I understand that failure to follow
aftercare instructions may result in permanent damage to my skin, scarring and may prevent the pigment from
settling. I agree to keep the procedure area clean and to follow aftercare instructions. This includes exercising,
tanning, and skincare products.

Any procedure that breaks the skin requires healing time, which can cause the healing process to be full of ups
and downs. Here are some important reminders about the healing process to note during your journey.

1. Always wash your hands thoroughly with antibacterial soap before touching the tattooed area
2. Do not wash or put anything on your tattoo that has not been given to directly by your artist.
3. Do not rub/scratch or traumatize the procedure area while it is healing; touching the procedure area with
your fingers may cause an infection from unseen bacteria. Furthermore, your fingers may have added oils
that can cause the pigment color to be removed.
4. Scabbing in a normal part of the healing process. Don't freak out if your scabbing comes off and it looks
like it's taking pigment away with it. This process can leave a "patchy' let the scabs fall off NATURALLY.
Picking your scabs can cause scarring, premature loss of pigment/hair and even an infection. The
approximate scabbing period is typically 7-14 days however, healing can be prolonged if you're immune
system is compromised if you are generally stressed, and by poor diet.
5. No makeup on/around your treatment area while healing.
6. No sweating (salt is your worst enemy and will draw out the pigment!); No heavy work outs, saunas, laying
out in the sun, swimming in chlorinated pools/ jacuzzi's/ocean until area is completely healed.
7. Absolutely no sun exposure or tanning for 3-4 weeks after procedure.
8. If you are a "face-sleeper" then sleeping on clean, satin pillowcase is suggest while the procedure area is
healing.
9. If you're a blood donor, you may not give blood for 1 year following your procedure (Per Red Cross)
10. Trust the process!

POLICIES
I understand that there is NON -refundable, but transferable, deposit to hold my appointment. This amount
will go towards the remaining amount due before the time of my appointment. This amount will change
depending on the service
I understand that Ink by Nada will assess a late fee charge of $35.00 if I am more than 15 minutes late to my
appointment. If I arrive more than 30 minutes late, I will forfeit my appointment and will need to reschedule at
a later time.
I understand that Ink by Nada has the right to forfeit my appointment at any given time if I fail to adhere to
their policies or any part of the permanent makeup treatment process.
Touch-ups that are scheduled outside of the allotted time frame/grace period will incur a $100.00 fee.
CONSENT & RELEASE AGREEMENT

I am over the age of 18, am not under the influence of drugs or alcohol, I am not pregnant or nursing and desire
to receive the indicated semi-permanent pigmentation procedure. The general nature of cosmetic micro-
pigmentation, as well as the specific procedure performed has been explained to me. Furthermore, I consent to
the following:
To my knowledge, I DO NOT have any physical, mental or medical impairment or disability that might affect
my wellbeing as a direct or indirect result of my decision to have the procedure done at this time.
_________ (initial)

I have been informed of the nature, risks, and possible complications and consequences of permanent skin
pigmentation. Understanding that permanent skin pigmentation procedure carries known, and unknown
complications and consequences associated with this type of cosmetic procedure, including but not limited to:
infection, scarring, inconsistent color, and spreading, fanning or fading of pigments.
_________ (initial)

I authorize my technician to use his/her professional judgment to decide what he/she feels is necessary under
the given circumstances that any unforeseen conditions arise during the course of my procedure.
_________ (initial)

I fully understand this is a tattoo process and therefore not an exact science but an art.
_________ (initial)

I accept the responsibility for determining the color, shape and position of the micro blading procedure as
agreed during consultation.
_________ (initial)

I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin.
I fully understand and accept that non-toxic pigments are used during the procedure and that the result
achieved may fade over a period of 1-3 years. Even once the color fades, pigment itself may stay in the skin
indefinitely.
I have been informed that the highest standards of hygiene are 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
desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may
have to return for a repeated procedure.
Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-
4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however,
using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully
healed.
_________ (initial)
I have been advised that the true color will be seen 6 weeks after each procedure, and that the pigment may
vary according to skin tones, skin type, age and skin condition.
Aftercare instructions have been explained to me and a written copy will be given to me to retain in my
possession, which I will follow the best of my ability. If I have questions, I will call or email you.
I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the
technician. Failure to do so may jeopardize my chances for a successful procedure.
_________ (initial)

I understand that Retin A. Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They
will alter the color .
Retin- A: Originally used as an acne treatment but now has numerous uses, including an exfoliating agent and
"Keratolytic" (a product that removed a plug out of a hair follicle or sweat gland)
Alpha hydroxy acids (AHAs): is the group name for several types of acids that are naturally found in different
foods and plants. They're a group of "peeling" agents that exfoliate chemically. They help prevent dead skin
cells from sticking together, making it easier to exfoliate and giving you a more radiant, glowing skin.
Glycolic acid is part of the group of active compounds known as AHA's (alpha hydroxy acids). Derived from
cane sugar: It has the smallest molecules in the group so is able to penetrate skin deeply and easily, making it
the most effective for treating fine lines, acne, blackheads, dullness, oiliness etc.
_________ (initial)

I understand that sun, tanning beds, pools and some skin care products and medications can affect my
permanent makeup.
I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially
if I'm scheduled for an MRI.
I accept the responsibility for my explanation to you of my desire for specific colors, shape and position for any
procedure done today.
I understand that implanted pigment color can slightly change or fade overtime due to circumstances beyond
your control and I may need to maintain the color with future applications and touch up sessions, depending
on the service will be required within a specific time frame.

I acknowledge that the proposed procedure(s) involve risk inherent in the procedure and have possibilities of
complications during and/or following the procedures such as: infection, misplaced pigment, poor color
retention and hyperpigmentation.
I have been quoted the cost of today's appointment. This appointment does not include a touch up. The
remaining payment of the service(s) I've been quoted for today will be due the day prior to the service. I
understand that Ink by Nada does not provide refunds for this/these elective procedures if I cancel my
appointment less than 72 hours of my appointment date.
_________ (initial)

I understand that if I choose to reschedule my appointment, that the time I desire may not be avliable.If I need
to reschedule my appointment and it exceeds the two month (2 month) timeframe, I understand that I will be
charged an additional $100.00 for my initial service/touch up service.
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 my questions
have been answered. I acknowledge that I have reviewed and approved the materials given to me and I
authorize Nada Daud, owner and certified permanent makeup artist of Ink by Nada, to perform on my body the
Ink by Nada permanent makeup procedure desired today.

Signature

Date