-ARE YOU ON ANY MEDICATION? YES / NO (MEDICATION’S NAME:…..…….……..………………
If you are now taking or recently have taken (within last 6 months) any of these drugs please circle below.
Anticoagulants (e.g. Aspirin, Warfarin, Macumar)/ Antibiotics/ Antasuse/ Diabetic Meds/ Heart Meds /Herpes meds/ Roaccutane/ Blood Pressure Meds /Seizure Meds/Thyroid meds/ Hepatitis meds/Cortisone
-HAVE YOU ANY ACCUT/CRONIC/ IMMUNE/AUTOIMMUNE DISEASE? YES / NO
-DO YOU HAVE ANY SKIN DISORDERS(ECZEMA, PROSIASIS ,LUPUS,ACNE, COLD SORES, WARTS, ALOPECIA,BCG) YES / NO
-HAVE YOU ANY ALLERGIES TO ANYTHING? (E.G. LIDOCAIN, EPINEPHRIN, TETRACAIN) YES / NO
-ARE YOU DIABETIC OR EPILEPTIC? YES / NO
-HAVE YOU A CARDIAC PACEMAKER /ANY HEART DISEASE/CIRCULATION DISORDER? YES / NO
-HAVE YOU ANY SEXULALLY TRANSMITTED DISEASES? YES / NO
-HAVE YOU ANY HORMON PROBLEMS (E.G. THYROID)? YES / NO
-ARE CURRENTLY GETTING CHEMOTHERAPY OR ANY OTHER CANCER TREATMENT? YES / NO
-ARE YOU POSSIBLY PREGNANT OR BREASTFEEDING? YES / NO
-DO YOU HAVE HEPATITIS A, B OR C? YES / NO
-DO YOU WEAR CONTACT LENSES? OR HAVE YOU UNDERGONE EYE SURGERY RECENTLY? YES / NO
-HAVE YOU UNDERGONE ANY SKIN TREATMENT (E.G. LASER, MICRODERMABRASION, FACIAL) OR ANY PLASTIC
SURGERY/ANTI-AGING TREATMENT ON YOUR FACE IN THE LAST 6 MONTHS? YES / NO
-DO YOU GO ON HOLIDAYS/OR TO ANY SPECIAL EVENT WITHIN 2 WEEKS FROM THE INITIAL TREATMENT? YES / NO
-HAVE YOU EVER HAD INJECTIONS? (FILLERS) (IF YES, WHEN: ….. /…../ ……….) YES / NO
-HAVE YOU ANY BODY TATTOES? (IF YES, DID THEY HEAL WELL?..........) YES / NO
-DO YOU HAVE ANY KELOID SCARS? YES / NO
-HAVE YOU BEEN TO SUN BED THE LAST 5 DAYS? YES / NO
-DO YOU WEAR MAKE-UP /FAKE LASHES/ EYEBROW TINT /FAKE TAN TODAY? YES / NO
-DID YOU CONSUME ALCOHOL 48 HOURS PRIOR TO THE TREATMENT? YES / NO
-DID YOU DRINK ENERGIE DRINK/COFFEE/TEA 3 HOURS PRIOR TO THE TREATMENT? YES / NO
SIGNATURE OF CLIENT: …………………………………………………………………..………………………………………………….DATE: ………………………………………

DO YOU REQUIRE SKIN TEST? YES / NO
A patch test is advisable however it does not ensure a client will not have an allergic reaction.
I CONSENT…………………………………………………./ OR WAIVE ……………………………………………………… patch test(please initial).
If waived, I release the technician and salon form liability if I develop an allergic reaction to the pigment or any products used. (If you require a patch test you must wait 48 hours before we can start the procedure).
By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows: (Please initial the line next to the number after you clearly understand each statement)
1. ________ I understand that the process used in cosmetic tattooing is not a one-step process and may require multiple procedures to achieve the desired results. I realize that the healing process takes at least 4 weeks and that there will be at least 4 weeks between procedures, regardless of how many procedures are required to achieve the desired results.
2. ________ I understand that the fee for each touch-up session of permanent make up procedures is minimum half- price of the initial treatment and must be completed within 3 months of the initial procedure to qualify as a touch-up. Touch-up sessions of procedures completed by technicians other than Karolina Drelich or after 3 months of the initial procedure ranges from a minimum of 60% of full fee to 100% of full fee after 2 years. Payment is rendered upon completion of each session. There is a non-refund policy.
3. ________ I understand that this is a cosmetic tattoo and with time pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, and use of chemicals such as Retin-A and Glycolic acids. Touch-up maintenance work will be expected in the future to keep it looking fresh.
4. ________ I acknowledge that no guarantees have been made to me concerning the results of this procedure.
5. ________ I understand that there are some known possible complications of permanent cosmetic procedures including some minor bleeding, redness, swelling, puffiness, corneal abrasions, dark patches, allergic, reactions, pigment migration and tenderness. I also understand that this is normal to lose approximately 1/2 of the colour during the healing process.
6. ________ I realize that after the procedure the colour will appear to be too dark and that in about 6 days the colour will appear to change and that after about 10 days the colour will appear softer since the colour has moved from the dermal to the epidermal layers of the skin.
7. ________ I realize there will be a period of time when scabs may form and the skin will slough off and that I am not to touch these areas during this time.
8. ________ I understand the nature of the procedure and possible complications or adverse effects that may occur as a result of applied pigments, which include risk of infection, scarring, eye damage, inconsistent colour, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. I fully understand that this is tattooing process and therefore is an art not a science.
9. ________ I have received and acknowledged pre- and post procedure instructions and agree to strictly adhere to such instructions including refraining from wearing make up 7-10 days following the procedure. When I resume wearing make up I will use only new eyeliner, lipstick, mascara or brow pencil according to the procedure I have had done.
10. ________ I accept responsibility for determining the colour, shape and the position of the pigments that will be applied and will approve such applications before the procedure begins. I understand that actual colour of the pigment may be modified slightly due to the tone and colour of my skin and that because of the elasticity of the skin the shape may change slightly from that which I originally approved. However I know that every effort will be made to make the final result flawless.
11. ________ I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.
12. ________ I understand the taking of before and after photographs is required. I also understand that exceptional photographs or results may be used in advertising or promotional materials and give permission for such usage. I also understand that any photographs will not be used for such purposes if I withhold my permission.
13. ________ Treatments may be recorded. A proposed outline of the cosmetic tattoo will be drawn on the skin before the procedure commences. If propositions are not accepted, treatment will not be performed.
14. ________ I request the permanent skin pigmentation procedure, appreciating and accepting the permanency of the procedure. I consent to the application of permanent cosmetic tattooing and have following procedures performed:
a. Eyebrow’s initial micropigmentation My expectations: (color, shape, style)
b. Eyebrow touch-up treatment ………………………………………………………………………………….
c. Upper eyeliner initial treatment ………………………………………………………………………………….
d. Upper eyeliner touch-up treatment ………………………………………………………………………………….
e. Lower eyelid initial treatment ………………………………………………………………………………….
f. Lower eyelid touch-up treatment …………………………………………………………………………….……
g. Lip initial micropigmentation ……………………………………………………………………………….…
h. Lip touch-up treatment ……………………………………………………………………………….…
I. Correction treatment of other technician’s job /area(S)……………….………………………………………………………………………..…
15. ________ I further acknowledge that at the time of signing this consent to this procedure(s) I was of sound mind and capable of making independent decisions for that and myself no one has coerced me into making this decision; I am not under the influence of alcohol or drugs. I also agree not to hold either Karolina Drelich or anyone who may be assisting her liable for any reactions, outcomes or occurrences that may or may not result from having this procedure(s).
16. ________ I certify that I have read and initialed the above paragraphs and have had them 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 any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from or consequences of, the aforementioned procedure(s).
17. I AGREE to follow the aftercare instructions