Permanent Cosmetic Intake Form

Thank you for choosing me to take care of your

permanent cosmetic beauty needs.  

Please complete all sections immediately. 

Pre Procedure Advice

(Please Read In It's Entirety)

Please read the following advice carefully; if you have any questions please contact me at 214.538.4933


PERMANENT MAKEUP is not meant for the perfectionist. While I can do everything I can to make your procedure look perfect, they will NEVER be "Perfect". If this is you, permanent makeup is not for you.
•• Please come to appointment make up free.
•• If you are having a brow procedure; please DO NOT wax or shape your brows for 7 days prior to appointment.
•• If you are having a lip procedure; please sugar scrub daily for 7 days prior to your appointment.
•• If you are having an eyeliner procedure; please come to the appointment contact free.
•• Permanent make up procedures normally requires multiple treatment sessions. For best results, it is recommended for clients to return for at least one perfection appointment. This will take place 6-8 weeks after the initial procedure. Those with oily skin it may require an additional touch up. Please be aware that color intensity will be significantly darker and sharper immediately and a few days after the initial procedure, but the color will reduce by 20-30% for brows and lips and 0-5% for eyeliner.
•• Although numbing cream is used during the procedure, sensitivity or discomfort may still be felt. Skin may be red and/or swollen after the procedure.
•• Please do not consume caffeine products the day of the procedure.
•• Please do not drink alcohol 24 hours prior to the procedure.
•• Unless medically necessary, please avoid taking things that thin the blood like fish oils, herbals, Vitamin E, aspirins, etc. for 48 hours prior to procedure.
•• Consult your physician if you are taking any prescription blood thinners prior to discontinuing use. If applicable, please get a written and signed letter from physician stating you may discontinue use of blood thinners 48 hours prior to procedure. Bring this letter with you to your appointment.•• Where possible, try to avoid the following herbs and spices prior to your appointment: Black pepper, Cardamom, any member of the Zingiberaceae (Ginger) family, Cayenne, Cinnamon, Garlic, Horseradish, Mustard.
•• A patch test can be performed, unless waived by client. It is the client’s responsibility to schedule this at least 1 week prior to the procedure.
•• Botox, AHA products and retinoids should be avoided for 2 weeks prior to the procedure and two weeks post procedure.
•• Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure and 2 weeks post procedure and avoiding direct contact to procedure area.
•• Chemical and laser peels should be avoided no less than 6 weeks prior to procedure.
•• Patients prone to cold sores/fever blisters should take an anti-viral prior to treatment.•• Hormone therapies can affect pigmentation and/or cause sensitivity.
•• Discontinue use of any brow-growth serums like Latisse, as it can cause sensitivity or affect pigment for 7 days prior to procedure.
••You are STRONGLY discouraged from bringing children with you to your appointment.  Please know that I love children but the time reserved is for you and should be all about you.  I schedule time according to procedures being performed and most likely will have other clients coming in after you.  It is very important to have as few distractions as possible during your scheduled time to give you the best service you deserve.  
 
Topical Anesthetic Advice
•• 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.
•• 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.
•• Procedure – For all procedures, a numbing cream/gel is used. The products are formulated to be perfectly safe and can be purchased over the counter from any pharmacy/chemist. The anesthetic is placed over the treatment area for 15-30 minutes then carefully removed prior to treatment. 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.
 
Contraindications for Permanent Make Up
•• Liver disease – high risk of infection
•• Pregnancy/Nursing
•• Compromised skin near area being worked on
•• Chemotherapy/Radiation
•• Skin conditions like psoriasis, dermatitis, etc. near the area being worked on
•• The following medical conditions please contact me for further discussion: Diabetes Type 1 and 2, high blood pressure, auto-immune disease, thyroid / Graves’ disease or any other medical condition that causes slow healing or a high risk of infection.

Tell me a little bit about yourself.

Everything marked with a (*) is a required field & form will not be accepted if not completed.

** when selecting you birth date Select YEAR, then MONTH, then the DATE **

  • Female
  • Male
  • Non-Binary
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Texas Department of Health requires me to validate your age by means of ID verification when having a permanent make-up (ie. tattoo) procedure.  

** when selecting the expiration date Select YEAR, then MONTH, then the DATE **

Tell me a little about your

skin and health.

What best describes your skin type before sun exposure?  Here is the Fitzpatrick Scale descriptions; please make selection below:

Fitz 1 - skin tone ivory, eye color: light blue, light gray, or light green natural hair color: red or light blonde sun reaction: skin always freckles, always burns and peels, and never tans

Fitz 2 - skin tone fair or pale, eye color: blue, gray, or green natural hair color: blonde sun reaction: skin usually freckles, burns and peels often, and rarely tans

Fitz 3 - skin tone fair to beige, with golden undertones eye color: hazel or light brown natural hair color: dark blonde or light brown sun reaction: skin might freckle, burns on occasion, and sometimes tans

Fitz 4 - skin tone olive or light brown, eye color: dark brown natural hair color: dark brown sun reaction: doesn’t really freckle, burns rarely, and tans often

Fitz 5 - skin tone dark brown, eye color: dark brown to black natural hair color: dark brown to black sun reaction: rarely freckles, almost never burns, and always tans

Fitz 6 - skin tone deeply pigmented dark brown to darkest brown, eye color: brownish black natural hair color: black sun reaction: never freckles, never burns, and always tans darkly

Which best describes your ethnicity background?

Booking and Retainer Fee

~I understand ALL appointments REQUIRE a $50 booking retainer to hold your appointment time.  (Unfortunately, I have been forced into this policy due to the amount of people booking and cancelling at the last minute or just not bothering to show up leaving a 3-hour gap in my schedule that could have been utilized by someone like yourself.) 

~I understand that the booking retainer will be applied to my final cost of the appointment.

~I understand that I am to abide by the cancellation and reschedule protocol OR the booking retainer WILL BE forfeited and applicable charges will have to be made/settled if I wish to reschedule.  Current cancellation and rescheduling protocols are kept on the website for All About The Brow and is sent out via text in informational messages.

Client Photo Release

All the photos and/or videos used will be clinically appropriate and tastefully presented.

I agree that the photographs that Marla Nutter/All About The Brow chooses to be used and it is understood that these photos may appear on website, social media accounts (Facebook, Instagram, Google, etc.), and in-office for demonstrational and promotional purposes.

I understand that I am not entitled to compensation for these photos being used. 

Informed Consent

I am over the age of 18, I am not under the influence of drugs or alcohol, I am not pregnant or nursing and desire to receive the indicated 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 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 make up procedure as agreed during pre-drawing on day of procedure. I fully understand and accept that nontoxic 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 permanent make up 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.
•• 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.
•• I understand that with oily skin types, strokes can heal less crisp, expanded and/or blurry and may result in a powder-brow effect.

•• 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 post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.
••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 understand that if I have any skin treatments, injectables like Botox or filler, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent make up procedure. I acknowledge some of these potential adverse changes may not be correctable. 

Disclosure and Release

~I understand permanent make up can last 6-18 months up to multiple years depending on how my skin reacts to the procedure. There may be fading and/or discoloration and the result may not be what I expected to receive. I understand this is a permanent makeup procedure that may take mutiple follow-ups and touch ups to get desired result. I understand it is strongly recommended I schedule the touch up for 6 to 8 weeks after my initial treatment.
~I understand 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 understand that I will be given the opportunity to view and approve the pre-draw shape that my artist creates. 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. 
~I understand there may be discomfort and pain during this procedure even though topical anesthetic is applied before, during and after procedure.
~I understand there is a possibility of bleeding, swelling, redness and allergic reactions to pigments. 
~I understand permanent make-up can fade over time and that permanent make-up may last permanently and may not fade at all. 
~I understand surgical procedures may be required to remove pigment from skin. These procedures may cause scarring and permanent damage to the skin. 
~I understand that permanent make-up 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. Permanent make-up is not a replacement for a “make-up” look and some clients may still feel the need to add over the counter cosmetics.

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