New Client Intake

Personal Information

Have you ever had permanent makeup procedure before?

Thanks for submitting!

Treatment Interested
For Brow Client
Do you have mole, scar, or other anomalies in or around the brow area?
Do you have or have had a piercing in the brow area?
Have you had a hair transplant for your eyebrows?
For Eye Client
Do you wear contact lenses?
Do you use Latisse or eyelashes growth serums?
Do you currently have eyelash extensions?
For Lip Client
Have you ever had a Herpes Simplex Type I infection? Also called cold sores/fever blisters
Medical Questionnaires
For a more effective, personalized treatment, please be as accurate as possible when filling out the following information.
Are you under the care of a physician other than your PCP (primary care physician)?
Are you prone to keloid scarring, hypertrophic scarring, or any other form of excessive scarring condition?
Have you taken a medication containing Isotretinoin (e.g. Roaccutane) during the previous 12 months?
Do you have, or do you think it is possible you may have a Blood Borne Communicable Disease?
If so, please all applicable
Do you currently have any other form of communicable disease, or infection? e.g. respiratory infection, gastrointestinal infection, skin infection, ear or eye infection, bacterial, fungal or viral infection etc.
Do you have Diabetes, currently on any form of immuno-suppressant therapy, or have any other condition that may cause delayed healing?
Do you have any Hypersensitivity, Auto-Immune Disorder, or Allergic Conditions?
Have you ever taken a medication containing Bisphosphonate/Diphosphonate? e.g. fosamax, alendronate
Do you have any form of bleeding disorder, or are you taking any anticoagulants (blood thinners)?
Have you had any form of Cosmetic or Surgical Procedure, Radiotherapy, or Chemotherapy at any time during the past 6 months?
Do you suffer from any form of hyper-pigmentation skin conditions?
Do you suffer with fainting, blackouts, or seizures?
Do you have a cardiac pacemaker, Implanted Cardioverter Defibrillator (ICD), have a serious heart condition, or abnormal blood pressure?
Do you have any form of acute or chronic eye condition?
Are you prone to developing Telangiectasia? Spider vein
Do you smoke?
Do you have any allergies or sensitivity to latex/rubber?
Do you regularly sun bathe or use tanning salon?
Do you receive skincare treatments such as botox, filler, peels, etc...?
Are you currently taking any medications, herbs, vitamins?
Do you have a known allergy or sensitivity to any topical or local anesthetics including dental anesthetics?
Do you have a known allergy or sensitivity to any ingredients within tattoo ink or pigments, regular makeup, any preservatives, hair dyes, or other dyes?
Do you have a known allergy or sensitivity to any ingredients in tattoo aftercare creams, antiseptics, lanolin, or petrolatum (petroleum jelly)?
A patch test is offered in case of an allergic reaction to numbing agent and/or pigments. However, it does not ensure a client will not have an allergic reaction. If declined, I (client) release Golden Compass PMU Studio from liability if I (client) develop an allergic reaction to the pigment. If you require a patch test, YOU MUST contact us a week in advance to make an appointment for the patch test.
Do you need a patch test?
Please read the following statements carefully. Permanent makeup is a way of cosmetic tattooing, intended to be permanent lasting an average of 12-36 months or longer. On rare occasions, the pigment may migrate under the skin. The procedure of permanent makeup may be uncomfortable. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be performed if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after permanent makeup procedure, you should notify/ discuss with your doctor. Possible scar-ring may occur.
Click here for brows aftercare
Click here for eyes aftercare
Click here for lips aftercare
Click here for beauty mark aftercare
Click here for pmu/tattoo removal aftercare
Informed Consent for Permanent Makeup
I                                               am over the age of 18, am not under the influence of drugs or alcohol, 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 to be performed, has been explained to me.

If an unforeseen condition arises in the course of the procedure, I authorize my PMU

technician to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances.

I accept the responsibility for determining the color, shape and position of the permanent makeup procedure as agreed during consultation. 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 understand 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 repeat procedure.

The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care.

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. Please see after care instructions for more details. The procedure results will look acceptable for you to appear in public without additional make-up on the brows.

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. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.

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 agree to follow all pre-procedure and aftercare instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.

I can confirm that I have received a copy of aftercare details.

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it 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. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin.

I fully understand this is a tattoo process and therefore not an exact science but an art. I request the permanent skin pigmentation procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences of the said procedure.

I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent makeup procedure. I acknowledge some of these potential adverse changes may not be correctable.

I certify that I have read and initialed the above paragraphs and have had explained to my understanding the consent and procedure permit. I accept full responsibility for the decision to have this cosmetic permanent pigmentation work done.

I give permission to Vicky Nguyen of Golden Compass Permanent Makeup Studio permission to perform my permanent makeup procedure.

Disclosure & Release

Permanent makeup can last 12-36 months or longer depending on how my skin reacts to the procedure. There may be fading and/or discoloration. The result may not be what I expected to receive. I understand this is a permanent makeup procedure that may take numerous follow- ups and touch ups to get a desired result.

There is no warranty or guarantee made to me as a result of this procedure and the final result cannot be guaranteed. There are no refunds for this procedure, as results will vary and individual results are not guaranteed.

I have seen and agree with the pre-drawn shape that my artist created. I understand that this is a guideline for the shape and size of my brow design and it may vary slightly once the procedure is done.

There may be risks and hazard related to performing this procedure. There may be discomfort and pain during this procedure. There is a possibility of bleeding, swelling, redness and allergic reactions to pigments.

Permanent makeup is considered permanent and can/will fade over time. Permanent makeup, though permanent, may not last permanently and may fade. Surgical procedures may be required to remove pigment from skin. These procedures may cause scarring and permanent damage to the skin.

Final results cannot be determined until brows are completely healed at 4 to 6 weeks. I understand that permanent and semi-permanent makeup procedures cannot be guaranteed and results cannot be predicted, as there are many variables that contribute to the final result, such as aftercare, skin type, lifestyle, etc...

I have received post care instructions and will follow them to ensure results of my procedure are satisfactory.

I am NOT pregnant.

I am NOT under the influence of drugs and/or alcohol or any other mind altering substance.

I fully understand the procedure and give permission to my technician to perform the service of permanent makeup and all procedure and steps involved.

I have truthfully filled out the consent form and have informed my technician of all medications I have taken.

I release Vicky Nguyen of Golden Compass PMU Studio of all claims and injury, seen or unseen that may occur as a result of this procedure.

Photograph & Video Release

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

 

Photographic, audio or video recordings may be used for the following purposes:

  • educational presentations or courses

  • informational presentations

  • on-line educational courses

  • educational videos

  • promotional materials

 

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

 

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

 

This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only.

By signing, I testified that I read and fully understood the information provided above and confirm that all information provided by me is correct and truthful.
Signature