CONSENT

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CONSULTATION FORM | INFORMATION FORM | TOUCH UPS

Client’s name completing this document(Required)

Email address

Phone

For Josée Lemieux (President and Technician) at Maquillage Permanent Josée Lemieux inc.

Permanent Makeup / Dermopigmentation Treatment (Check each statement below if you have read and agree)

I UNDERSTAND that pigments will be implanted into the epidermal layers, at the boundary of the dermis.(Required)

I UNDERSTAND that pigments will be implanted into the epidermal layers, at the boundary of the dermis.

I UNDERSTAND that because this procedure involves working on the skin, results cannot be guaranteed. Results may vary depending on age, skin type, skin condition, and lifestyle.(Required)

I UNDERSTAND that because this procedure involves working on the skin, results cannot be guaranteed. Results may vary depending on age, skin type, skin condition, and lifestyle.

I UNDERSTAND that Maquillage Permanent Josée Lemieux inc. requires photographs, as well as personal information regarding my health and lifestyle habits, in order to provide safe services.(Required)

I UNDERSTAND that Maquillage Permanent Josée Lemieux inc. requires photographs, as well as personal information regarding my health and lifestyle habits, in order to provide safe services.

I UNDERSTAND that the term permanent refers to a duration that may vary over several years, and the term semi-permanent may correspond to several months. Pigment will gradually fade over time, along with its brightness.(Required)

I UNDERSTAND that several factors can diminish the longevity of permanent makeup. This includes genetical factors such as oily skin (which metabolizes pigment faster), autoimmune conditions, hormonal imbalances, thyroid issues, and certain medications. Lifestyle habits may also affect results, such as excessive sweating, sun exposure without protection, and the use of certain exfoliants (retinol, glycolic acid). Josée cannot be held responsible for these factors.(Required)

I CONSENT to pay the full amount related to my dermopigmentation treatment and understand that this amount is non-refundable.(Required)

I CONSENT to pay the full amount related to my dermopigmentation treatment and understand that this amount is non-refundable.

I UNDERSTAND that this treatment may require several appointments. The first touch-up is free and must be completed within 4 months following the initial application on the designated area. Additional visits will be charged separately. Any request to change color will incur a fee equal to half the original price.(Required)

I UNDERSTAND that the pigments used by Josée are extremely stable and typically last several years, but that no guarantee can be given. For the small percentage of clients whose pigment retention may be shorter, Maquillage Permanent Josée Lemieux inc. is not responsible. If this applies to me, fees starting at $250.00 CAD may apply to redo the treatment within the first 18 months.(Required)

Initials(Required)

Possible Risks and Complications (Check each statement below if you have read and agree)

I ACKNOWLEDGE that undetected health conditions may influence the final result of the dermopigmentation treatment.(Required)

I ACKNOWLEDGE that undetected health conditions may influence the final result of the dermopigmentation treatment.

INFECTION: The risk of infection is very rare and minimal. All instruments used by Josée are either single-use or sterilized. The treated area must be kept clean and touched only if necessary, and only with hands washed thoroughly with soap.(Required)

SWELLING & BRUISING: Depending on skin sensitivity, swelling or bruising may occur and usually disappears within 1 to 5 days. However, many clients experience no swelling, and bruising is very rare.(Required)

SWELLING & BRUISING: Depending on skin sensitivity, swelling or bruising may occur and usually disappears within 1 to 5 days. However, many clients experience no swelling, and bruising is very rare.

UNEVEN COLORATION: Minor bleeding, healing responses, or existing skin conditions may cause uneven pigmentation. It is very important not to rub or scratch the area for 2 weeks after each treatment. During the touch-up appointment (minimum 1 month after the initial treatment), we will adjust the pigment. In very rare cases, there may be permanent pigment deposits or pigment loss at the epidermal level.(Required)

I UNDERSTAND the nature of dermopigmentation and the risks involved, which have been explained to me beforehand, and I have had the opportunity to ask questions.(Required)

I UNDERSTAND the nature of dermopigmentation and the risks involved, which have been explained to me beforehand, and I have had the opportunity to ask questions.

ASYMMETRY: Every effort is made to avoid asymmetry. However, adjustments may still be required during the touch-up appointment (minimum 1 month after the initial treatment).(Required)

ASYMMETRY: Every effort is made to avoid asymmetry. However, adjustments may still be required during the touch-up appointment (minimum 1 month after the initial treatment).

ANESTHETIC: A topical anesthetic is used to minimize discomfort during the procedure. If you are allergic or have difficulty numbing, you must inform us.(Required)

ANESTHETIC: A topical anesthetic is used to minimize discomfort during the procedure. If you are allergic or have difficulty numbing, you must inform us.

I CONSENT to the use of topical anesthetics selected by Maquillage Permanent Josée Lemieux inc.(Required)

I CONSENT to the use of topical anesthetics selected by Maquillage Permanent Josée Lemieux inc.

PAIN: Some discomfort may occur after the procedure. You may take Advil or Tylenol (according to your usual habits), only if your health condition allows it.(Required)

PAIN: Some discomfort may occur after the procedure. You may take Advil or Tylenol (according to your usual habits), only if your health condition allows it.

I AGREE to follow all post-pigmentation instructions and aftercare recommendations that are explained to me.(Required)

I AGREE to follow all post-pigmentation instructions and aftercare recommendations that are explained to me.

Initials(Required)

Consumer(Required)

I CONFIRM that I am not under the influence of drugs or alcohol. To the best of my knowledge, I am in good physical and mental health.

I CONFIRM that I am over 18 years of age and do not have any health conditions that may contraindicate dermopigmentation, as indicated in my health information form.

I AGREE to call and reschedule my appointment if I have any lesions, health issues, or if I have received treatments in the same area less than two weeks prior to my appointment, as this may affect proper healing.

I have read and checked all statements (except the optional photo publication consent section, if applicable). I, the undersigned, hereby waive any claim, liability, legal action, damages, indemnity contribution, or complaint for fault, error, or omission under the law against Ms. Josée Lemieux and her team. This waiver also applies to all dermopigmentation tests and touch-ups. *(Required)

Add photo consent

CONSENT FOR PHOTO OR VIDEO PUBLICATION (Check each statement below if you have read and agree)

I UNDERSTAND that photos or video recordings of me may be shared publicly, and that if they are posted on the Josée Lemieux website or other online platforms, they will become accessible to the public.(Required)

FOR THE ABOVE-MENTIONED REASONS, I CONSENT to the team at Maquillage Permanent Josée Lemieux inc. or its authorized representatives photographing or filming me.(Required)

FOR THE ABOVE-MENTIONED REASONS, I CONSENT to the team at Maquillage Permanent Josée Lemieux inc. or its authorized representatives photographing or filming me.

I AUTHORIZE Josée Lemieux and her representatives to use, reproduce, publish, transmit, distribute, broadcast, and display photos or videos in which I appear or in which my voice may be heard, in any publication, multimedia production, video, exhibition, or advertisement for Josée Lemieux, including on her website or social media platforms, without further notice and without requiring my approval of the final version of the photos, videos, or testimonials.(Required)

Initials for Photo Consent(Required)

Additional photo consent details

Add tatoo removal consent

How long have you had your permanent makeup, approximately?(Required)

Which area needs to be tattoo-removed?(Required)

Have you already tried other tattoo removal techniques or used any lightening products? If so, which ones?(Required)

Magnetic tattoo removal treatment (Check the statements below if you have read and agree)*

I UNDERSTAND that the tattoo removal procedure uses magnetic needles that will create micro-lesions in the epidermis, and that the Tattoo Remoov solution will be applied afterward.(Required)

I UNDERSTAND that the tattoo removal procedure uses magnetic needles that will create micro-lesions in the epidermis, and that the Tattoo Remoov solution will be applied afterward.

I UNDERSTAND that the Tattoo Remoov solution is not an acid, a saline solution, an enzyme, or TCA, but an alkaline solution with a pH of 8.5.(Required)

I UNDERSTAND that the Tattoo Remoov solution is not an acid, a saline solution, an enzyme, or TCA, but an alkaline solution with a pH of 8.5.

I CONSENT to paying the fees per session for the tattoo removal, and I understand that these amounts are non-refundable.(Required)

I CONSENT to paying the fees per session for the tattoo removal, and I understand that these amounts are non-refundable.

I UNDERSTAND that the treatment requires multiple sessions.(Required)

I UNDERSTAND that the treatment requires multiple sessions.

I UNDERSTAND that tattoo removal is a procedure and not an exact science. We will try to remove as much pigment as possible, but there is no guarantee regarding the amount of pigment that will be removed at each session.(Required)

I UNDERSTAND that the results of tattoo removal may vary depending on your age, skin type, as well as the pigments, nature, quality, depth of implantation, and age of the makeup.(Required)

I UNDERSTAND that the results of tattoo removal may vary depending on your age, skin type, as well as the pigments, nature, quality, depth of implantation, and age of the makeup.

I AM AWARE that unidentified health issues could influence the final result of the tattoo removal.(Required)

I AM AWARE that unidentified health issues could influence the final result of the tattoo removal.

INFECTION: The risks of infection are very rare and minimal. All instruments used by Josée are single-use and/or sterilized. The treated area must be kept clean and touched only if necessary with hands thoroughly washed with soap.(Required)

SWELLING & BRUISING: Depending on the sensitivity of your skin, you may experience swelling and bruising, which will disappear within 1 to 5 days. However, many clients experience no swelling, and bruising is very rare.(Required)

UNEQUAL COLORATION: Slight bleeding, the healing process, or the condition of your skin prior to treatment may cause uneven coloration. It is very important not to rub or scratch the area for 2 weeks after each tattoo removal session.(Required)

I UNDERSTAND the nature of tattoo removal, as well as the associated risks that were previously explained to me, and I have had the opportunity to ask questions.(Required)

I UNDERSTAND the nature of tattoo removal, as well as the associated risks that were previously explained to me, and I have had the opportunity to ask questions.

I AGREE to follow all the post-tattoo removal instructions and care that are explained and recommended to me.(Required)

I AGREE to follow all the post-tattoo removal instructions and care that are explained and recommended to me.

Initials for Tatoo Removal Consent(Required)

Comment or message

Vocal consent

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