Semi-Permanent Makeup Questionaire

Client Information

Client Name*
Address*

Medical History

PLEASE COMPLETE THE MEDICAL HISTORY FORM BELOW


Do you wear contact lenses? if YES, please remove before procedure and should not be replaced until 48 hours. Please remember to bring your eye glasses if necessary.
Have you had surgery around the eye area?
Are you allergic to anesthetics?
Do you have allergies to any of the following?
Do you have a tattoo?
Are you pregnant?
Do you have any kind of heart condition?
Are you a diabetic?
Do you bruise easily?
Do you have any serious medical conditions?
Have you ever tested positive for COVID-19, HIV or Hepatitis?
Are you presently taking any medications, including immunosuppressive, such as anti-inflammatory or steroids?
Are you able to have over the counter antihistamines? (i.e. Benadryl )
Does your skin swell very easily?
Are you allergic to topical antibiotic preperations? (i.e. Polysporin, Neosporin etc.)
Do you use Retin-A or Hydroxyl (Glycolic) Acid? These products will FADE TATTOO AREA. Effecting long lasting results.
Have you ever had a fever blister, cold sore, or canker sore? This is most important for Lip Liner or Lip fill Permanent Makeup procedures.
By signing below I acknowledge that I have read and understand the above and all of my questions have been answered:
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Parent or Legal Guardian Name - Required if Client is under 18 years old
Required if Client is under 18 years old. Use your mouse or finger to draw your signature above

Authorization & Consent Form

GLOW DAY SPA INC. AUTHORIZATION AND CONSENT FORM FOR SEMI-PERMANENT MAKEUP (MICROPIGMENTATION) FOR: EYELINER, EYEBROWS, LIPS, RECOLORATION AND SCAR CAMOUFLAGE.


Please read the statements below, confirming you understand the following completely:


The undersigned hereby consents to Glow Day Spa taking photographs of the undersigned both before and after any procedures being undertaken by Glow Day Spa at the request of the undersigned. It is further understand, acknowledged and herein authorized for Glow Day Spa to use said photographs for the purpose of Glow Day Spa compiling an album of its various clients for the purposes of showing prospective clients the procedures completed by Glow Day Spa in its normal course of business. In the event the undersigned does not wish Glow Day Spa to use said photographs in its prospective client photo album then the undersigned shall expressly so state by informing the technician and said photos will be solely for the clients own file and client history for use internally in the development and monitoring of all services provided.  


The undersigned further acknowledges that it has been advised by Glow Day Spa not to drive a motor vehicle or operate any machinery or equipment for a period of not less than eight hours after a semi permanent makeup procedure and the undersigned further hereby saves harmless and indemnifies Glow Day Spa from any damages whatsoever resulting from the undersigned not compiling with the request of Glow Day Spa as stated herein.


The undersigned further accepts full responsibility for an indemnifies and holds Glow Day Spa and Kimberly Crook harmless and without liability of any kind whatsoever for the pigment coloration and position of all permanent make-up on it’s eyebrows, eyeliner, lips and any corrective and camouflaging procedures.


The undersigned further understands and acknowledges that no hair removal such as tweezing, waxing or electrolysis will have been performed or completed within one week prior to commencement of the procedure herein consented to.


That no warranty or guarantee has been made to me as a result of this semi-permanent makeup / camouflage / correction procedure, and that the final result cannot be guaranteed.


The undersigned having read the above acknowledges that all of the procedures contemplated and consented to herein have been fully explained and the undersigned fully understand the nature, scope and repercussions of the procedure herein consented to being performed and the undersigned herein fully accepts responsibility for any and all results of the said procedure.


The undersigned further acknowledges that any information provided by the undersigned to Glow Day Spa is being provided for the purposes of Glow Day Spa own internal compilation of information and under no circumstances is it deemed to be given for the purpose of Glow Day Spa, Kimberly Crook or any of its employees giving or making any medical decision, opinion, diagnosis or representation to the undersigned or any other party whatsoever.


The undersigned herby consents to Glow Day Spa and Kimberly Crook performing the treatments more specifically described below and the undersigned in consideration of Glow Day Spa and Kimberly Crook completing the below procedures hereby forever releases and further agrees not to make any claim or demand or commence, maintain or prosecute any action cause of proceeding for damages, compensation, loss or any relief whatsoever existing or relating to the procedures performed as described herein.

i.e. Eyebrows, Eyeliner, Lip Liner, Full Lips, Scar Camouflage, Aerola Correction, Beauty Mark

The undersigned further agrees that this release shall operate conclusively as estoppel in the event of any such claim, action or proceeding and may be pleaded accordingly. This release shall be deemed to have been made in and shall be construed in accordance with the Laws of the Province of Ontario, Canada. This release shall ensure to the benefit of and be binding upon Glow Day Spa the undersigned and their respective administrators, legal personal representatives, successors and assigns.


In WITNESS WHEREOF the undersigned has cause this release to be executed on this:

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Parent or Legal Guardian Name
Required if Client is under 18 years old. Use your mouse or finger to draw your signature above
Witness Name - Employee of Glow Day Spa
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