Consent Form

Consent form – powder ombre brows

Name

Phone

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Do you have any permanent cosmetics or tattoos on the areas being treated? yesno

Ethnic background, please include all nationalities. Your ethnic background will provide important insight and information relative to your skin tone and are critical when choosing pigment color(s); please be as detailed as possible. *African American CaucasionNativeAsianPacific IslanderHispanic/LatinMiddle easternMulti racial (Make sure to tell me which) Other

Are you allergic to anything? *YesNo

Do you regular exercise regularly? YesNo

Are you pregnant or nursing? *YesNo

Does your skin form Hyper-pigmentation (darkening of the skin) or Hypo-pigmentation (lightening of the skin) or marks after physical trauma? *No Hyper-pigmentHypo-pigment

Consent & Release Agreement

This form is designed to give information needed to make an informed choice of whether or not to undergo Eyebrow, Microblading, Microshading, Eyeliner, Lip blushing or any other semi-permanent makeup application.

If you have any questions, please don’t hesitate to ask. Although Permanent make up is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

Please Note: This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent, it is considered a permanent marking.

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. If at any point the area treated becomes red, itchy, oozing, overly inflamed these are possible signs of infection, you must contact a doctor or go to the nearest medical facility immediately.

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 and perhaps you may need an additional touch up at an additional cost.

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.

An annual color boost is suggested every 12-16 months, however everyones skin behaves differently so a touch up may be needed sooner.

Photography Release Consent

Client understands that The Brow Babe will use photos of my progress for marketing & advertisement purposes. You may disclose if you prefer to not have your face shown, more than likely it will be an up close image of an eye, brow or lips. I will only use full face if granted permission by the client. I grant permission.

Date

Signature

Possible Risks, Hazards, or Complications

• 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 but can happen, if at any point the area treated becomes tender to the touch, red, oozy, etc you should contact a healt professional immediately. 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 out faces our 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 me now.

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

• Allergic Reaction: Although an allergy is unusual, there is always a possibility of an unknown allergy to the pigments and materials used during procedure.

The alternative to these possibilities is to use traditional cosmetic and NOT undergo the Semi-Permanent Eyebrow, Lip Blushing, Eyeliner, Or any other semi permanent makeup procedure.

Date

Signature

Consent & Release Agreement

By checking the I Understand box, you are initialing that you fully understand that you are entering a legally binding contract

Please read the following statements carefully and initial to acknowledge your understanding of each.

Although rare, the pigment can migrate under the skin. I Understand

I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.I Understand

I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup. *I Understand

I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI. I Understand

The micropigmentation procedure may be slightly uncomfortable.I Understand

Pigment can appear 30-50% darker than desired result immediately following and the day after procedure. I Understand

Although rare, there may be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the procedure. Seek immediate medical attention in the event of a suspected reaction I Understand

I understand that exercising during the healing process can alter the desired effects of my procedure. I cannot hold the Artist responsible for poor retention. If at at any point artist finds evidence that any of these rules have not been followed. Artist has the right to release me as a client or to charge me for an additional touch up at the price an Annual Color Boost. I Understand

Permanent Makeup is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure. Additional touch ups may be needed. This means After your 2nd session if you need a 3rd session, you will be required to pay for the third touch up UNLESS the artist says otherwise *I Understand

I accept the responsibility to explain to you by desire for specific colors, shape, and position for any procedure done today. I Understand

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 6-12 weeks of initial procedure.I Understand

I acknowledge that the proposed procedures(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, hyper-pigmentation, scarring, bleeding, & nerve damage.I Understand

Allergic reactions to anesthetic can occur, seek immediate medical attention in the event of a suspect reaction. I Understand

It is illegal to apply permanent cosmetics to women who are pregnant or nursing.I Understand

It is illegal to apply permanent cosmetics to anyone under the age of 18 without parental consent. Even then it is up to the artist *I Understand

Infections can occur if after care instructions are not followed correctly. *I Understand

Not following my Pre Care & Aftercare instructions completely may result in poor retention, uneven healing, scarring etc. *I understand

If the Artist deems that you have not followed the Pre Care & After Care adequately, This can result in dismissal with zero refunds, or I will be charged regular price for a touch up. I understand

I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment Touch- ups must be completed within the time frame given to me by the artist. I understand

There may be swelling, redness or minor discomfort following the procedure. I understand

from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, which the Client now has or which hereinafter may have, against the Artist by reason of or in any way related to the Procedure. The Client agrees to indemnify and hold harmless the Artist, its principals, agents, and employees from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, resulting from, or in any way connected to, the Procedure. I understand

Scarring is rare but may occur. *I understand

I have read, understand and agree to adhere to all "The Brow Babe' Policies as outlined on their website. *I understand

Care and Maintenance

I agree to follow the care and maintenance instructions provided by the Artist for the care of the Procedure area following the Procedure, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that failure to follow aftercare instructions may result in permanent damage to my skin, scarring and may prevent the pigment from settling. I agree to keep the Procedure area clean and to follow aftercare instructions. This includes exercising, tanning, and skincare products. *I understand

No Known Medical Conditions / Informed Consent

I have read and completed the Procedure Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as keloid scarring, or infection) that the Procedure may cause to those who have specific medical or skin conditions. I understand that in rare cases persons may be allergic or have hypersensitivity to some of the products used during the Procedure. I understand that allergies to pigments may develop at any time after the Procedure, while the pigment is implanted in my skin. I further state that I have no known medical condition that might be aggravated by the Procedure or any medical condition that would prevent me from complying with or heeding to the Artist’s instructions or these warnings. I Understand

Spot & Patch Testing

I understand, that should I have any concerns about any possible reaction to the chemicals and products used, I may arrange at my own discretion to book an advance spot test where topical anesthetics and pigment will be applied to my skin externally, 24-48 hours prior to the time in which I’m scheduled for the Procedure. I also understand that spot testing does not guarantee that no future sensitivity or reactions will develop. I agree that scheduling a spot test shall be my own responsibility and at my sole discretion, and have absolutely no bearing on the contents or signing of this Agreement or any clauses contained therein. *I understand

Right to Refuse Service

Though it is extremely rare, we reserve the right to refuse treatment for the following reasons. The full service fee will still apply, as we are not able to sell this time to another client. •Undisclosed skin condition (including sunburn/suntan) •Using Retin-A & Skin care products •Under the influence of drugs or alcohol •Any behavior which, in the opinion of the artist , might compromise the artist’s ability to work safely and comfortably toward the desired results, or might disrupt other clients. •Being Rude, Nasty, Calling, Texting repeatedly or cursing at the artist. This does not happen very often because who would be rude & nasty to the artist whom you want to tattoo your face? However, if this does happen the artist reserves the right to dismiss the client. All efforts will be made to rectify the situation, but if artist feels it has gone to far or that the client can not be made happy. The artist has the right to refuse treatment and no monies will be returned/refunded. I understand

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or poor retention on the tattooed area. I am aware that it is my responsibility to inform the Artist of my current medical and/or health conditions, as well as update this history on forms as appropriate. This is an elective procedure, with no guarantee's. I release Glam India Threading & Spa from liability and assume full responsibility thereof. Yes

I certify that I have read or have had read to me the contents 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 authorize Glam India as my technician to perform on my body. I consent

Signature

Date

Photo of Govt. ID

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BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE COMPANY. Please type your full Legal Name. *I consent

Signature

Date

Microneedling in Arlington and Bedford

Consent Form