Book an Appointment
Manage Appointment
Our Story
Shop
Other
CONTACT OPTIONS
One Location Small Map
GIFT CARD OPTIONS
Horizontal
CAREER
Position Details
OTHER PAGES
Blog
FAQ
Contact
SPMU Release Form
Please complete this form before attending your SPMU appointment. Without completion of this medical release, we will not be able to complete the procedure. Please answer all questions truthfully.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Phone
*
GP Address
*
Address Line 1
City
State / Province / Region
Postal Code
Medical Questions
This section will cover your medical history. Please make sure to answer these questions truthfully.
Do you have any Flu-related symptoms?
*
Yes
No
Symptoms might include a fever, shortness of breath, loss of taste, continuous cough.
Have you taken Aspirin, Ibrupofen, Warfarin or Alcohol in the past 48 hours?
*
Yes
No
Have you received Chemotherapy or Radiotherapy in the past year? If so, do you have a letter from your consultant/GP confirming you are well enough to receive semi-permanent make-up?
*
Yes
No
Please list any medications you have taken in the past 6 months:
Do you have any allergies?
Have you ever had one of the following?
Retain A/Retinol within the past 2 weeks
Anemia
Sensitivity to cosmetics
Prolonged Bleeding
Trichotilomania
Low Blood Pressure
Artificial Heart Valves
Diabetes
Cancer
Hemophilia
Fainting Spells
Dizziness
High Blood Pressure
Liver Disease
Circulatory Problems
Epilepsy
Tumors, Growths or Cysts
Herpes
Thyroid Disturbance
HIV
Hair Loss
Hepatitis
AHA Preparation within past 2 weeks
Fat, Botox Collagen Injections
Hypertrophic Scars
Keloid SCSR
Healing Problems
Do You Easily Scar?
Are You Pregnant/Nursing?
Are You Taking Bloodthinners?
If you answered yes to the question above, please provide more information:
Have you ever had an allergic reaction to the following?
Latex
Lanolin
Lidocaine
Vaseline
Hair Dyes
Body Paints
Metals
Medications/Drugs
Anaesthetics/Adrenaline
Foods
If you answered yes to the question above, please provide more information:
Signing
Risks
*
I Agree
That I have been fully informed of the risk associated with Semi-Permanent Makeup. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, difficulties in detecting melanoma and allergic reactions. Having been informed of the potential risks, I still wish to proceed with the SPMU application and I freely accept and expressly assume any and all risks.
Waive
*
I Agree
TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Studio from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from my tattoo, whether caused by the negligence or fault of either the Artist or the Salon, or otherwise.
Healing
*
I Agree
The Artist and the Salon have given me instructions on the care of my SPMU while it's healing, and I understand them and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me.
Influence
*
I Agree
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist without duress or coercion.
Health
*
I Agree
I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I do not have any other condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the preventive anti-biotics. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.
Colour Intensity & Fading
*
I Understand
Pleased be prepared that color intensity will be significantly darker and sharper immediately after the procedure. This will reduce 30%-50%
Permanence
*
I Understand
SPMU And Microblade is a permanent change to my appearance and can only be removed by laser or surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of my skin.
Questions
*
I Agree
I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions have been answered, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the Salon.
Touch-Up
*
I Understand
I understand that a touch-up is required after the first appointment, to achieve the best results. I will not receive this touch-up until 6 weeks after my appointment.
Signature
*
Clear Signature
Submit
Service Menu
Our Story
Shop
Other
Contact One Location v2
Gift Cards Horizontal
Position Details
Blog
FAQ