U&I Spa Inc

130 West 57th Street, Suite 14A
New York, NY, 10019
Phone: 917.214.9910
Email: uandispa@gmail.com

Please answer all questions below and press the [SUBMIT] button on all forms.

1. CLIENT MEDICAL HISTORY FORM

*Do you have or previously had the following? Select YES or NO
I agree that all the above information is true and accurate to the best of my knowledge.

2. STATEMENT OF CONSENT AND RECITALS:
Please read and initial all lines

I. I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.
II. I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.
III. I understand that Retin A, Renova, Alpha Hydroxy, and Glycolic Acids must not be used on the treated areas. They will alter the color and cause premature exfoliation of the pigment.
IV. I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup.
V. I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue.
VI. I will tell all skin care professionals or medical personnel about my permanent makeup procedure, especially if I am scheduled for an MRI.
VII. I accept the responsibility to explain to you by desire for specific colors, shape, and position for any procedure done today.
VIII. I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications, and a touch up session within 60 days.
IX. I acknowledge that the proposed procedure(s) involve risks inherent in the procedure, and have possibilities of complications during and / or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
X. I have been advised that a touch up session is highly recommended to make any adjustments to shape, color, and to fill in any pigment that may have had poor retention. Touch ups must be completed within 60 days of the initial procedure.
X. Aftercare instructions have been explained to me and a written copy has been given to me retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or text my Specialist.
I certify that I have read and have had read to me to consents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize my Specialist /Technician to perform on my body the permanent/semi-permanent procedure desired today.
Please be aware that discounted offers (Groupon, Living Social, Gilt, Class Pass etc) are only for first time clients (one-time use). All services in this package of up to 3 sessions will expire after 6 months from purchase date. All services in the package of 6-8 sessions will expire after 1 year from purchase date.

3. POSSIBLE RISKS, HAZARDS, OR COMPLICATIONNS

Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others.



Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See “After Care” sheet for instruction on care.



Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow up appointment will likely correct any uneven appearance.



Asymmetry: Every effort will be made to avoid asymmetry, but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness.



Excessive Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don’t bruise or swell at all.



Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, prilocaine, Benzocaine, Tetracaine, and or Epinephrine cream and or liquid are used. If you are allergic to any of these, please inform your Technician now.



MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may be required be required if you need to scanned by an MRI machine. You must inform your MRI Technician of any tatoos or permanent cosmetics.



The alternative to these possibilities is to use the traditional cosmetic and NOT undergo the Permanent/Semi-Permanent procedures.

Consent and release for procedures performed:

4. CONSENT AND RELEASE AGREEMENT

This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent/semi-permanent makeup application. If you have any questions, please don’t hesitate to ask.

Although permanent/semi-permanent makeup is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

3D eyebrow Microblading is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent.

All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after use. Cross contamination guidelines are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual and advised to expect a Touch-Up after healing is completed.

Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time. Additional Touch ups are likely needed within 6 months to 2 years.

5. PHOTOGRAPHY RELEASE CONSENT

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.