Boise Brows Permanent Cosmetics Information and Consent Forms

Date

Name

First NameLast Name

Date of Birth

Date

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Day/ Cell Phone

Email

example@example.com

Emergency Contact

Name and number

Relationship

Who may we thank for referring you?

Procedure Desired

Permanent Brows $600

Touchup (within 6 months) Tray Fee $50

Annual Touchup (6-36 months) $250

Touchup 36 months + is treated as a new procedure and will incur the same cost

Upper Eyeliner $350 Winged liner $450 (add lowers $50)

Tinted Lips $500

Correction work is by consultation only and no pricing will be given based on the unknown number of appointments needed to correct previous work

Are you Pregnant or Nursing?

YesNo

Do you Consume Aspirin daily?

YesNo

Have you had any alcohol in the last 24 hours?

YesNo

Are you under treatment for depression?

YesNo

Have you ever had cold sores or fever blisters?

YesNo

Do you have any type of herpes virus?

YesNo

Do you have allergies to latex?

YesNo

If you have permanent cosmetics or tattoos did you have any problems with them healing?

YesNo

Have you had laser or chemical peels within 6 months?

YesNo

Are you undergoing radiation or chemotherapy?

YesNo

Have you ever had any permanent cosmetics or tattoos?

YesNo

Are you now or have you ever been on accutane?

YesNoOther

Do you bruise easily or for no obvious reason?

YesNo

Do you have a pacemaker?

YesNo

Do you routinely use Retin-A, Glycolic, or other exfoliating products?

YesNo

Do you take prescription medications?

YesNo

Do you wear contact lenses?

YesNo

Are you anemic?

YesNo

Do you have problems healing?

YesNo

Do you have sensitive skin?

YesNo

Is your skin oily?

YesNo

Do you have allergies to makeup?

YesNo

Do you use tobacco? If you use tobacco you may heal slower and this may affect the timing for a touchup appointment.

YesNo

Do you have any medical condition that requires you to pre-medicate with an antibiotic prior to dental procedures?

YesNo

Do you have a heart condition?

YesNo

Do you have dry eyes?

YesNo

Are you diabetic?

NoType 1Type 2

Do you intentionally tan in the sun or use tanning beds?

YesNo

Do you have an autoimmune disorder

YesNoOther

Do you have a personal history of cancer?

YesNoOther

Do you have botox injections? When was your last injection?

YesNoOther

Do you have a history of stroke or heart attack?

YesNo

Do you hyper-pigment? Tendency to develop dark spots on the skin from wounds or sun?

YesNo

Do you hypo-pigment? Lose pigment in the skin when wounded?

YesNo

Do you tend to develop keloid or hypertrophic scars?

YesNo

Are you allergic to hair dye?

YesNo

Do you scar easily from minor injuries?

YesNo

Do you have glaucoma or other eye disease?

YesNo

Do you have any seizure related conditions?

YesNo

Do you have arthritis?

YesNo

Do you have a tendency to faint or become dizzy?

YesNo

Do you have high or low blood pressure?

YesNoOther

Do you bleed excessively from minor cuts?

YesNo

Do you have sinus problems?

YesNo

Have you had lasik or vision correction surgery in the last 3 months?

YesNoOther

Are you prone to eye infections? (conjunctivitis/ pink eye) or herpes of the eye?

YesNo

Are you on blood thinning medications?

YesNoOther

Are you on steroids or anti-inflammatory medications?

YesNoOther

Have you had an organ transplant?

YesNo

Do you swell easily?

YesNo

Are you currently tanned in the areas to be treated?

YesNo

Do you have hemophilia or clotting disorder?

YesNo

Have you ever had Hepatitis A, B, or C?

YesNoOther

Do you have any pre-existing nerve damage in the area to be treated?

YesNo

Do you have a thyroid condition?

YesNo

Do you have Alopecia (loss of hair)?

YesNo

If you answered “yes” to any question above does not indicate that you are not an acceptable candidate for permanent cosmetics. It may simply be information that is valuable to me as your technician as each person’s body is unique, or it may indicate that it would be advisable or required that you consult with you physician before proceeding.

If this form has not addressed a medical condition you have, Please note here:

Please list any medications or supplements you are taking:

Please list any allergies you may have:

Name

First NameLast Name

The nature and method of the proposed cosmetic tattoo procedures have been explained to me by Cori Simons including the usual risks inherent in the procedure process, and the possibility of compli cations during and following the procedure. I understand there may be a certain amount of discomfort or pain associated with the procedure and that other adverts side effect may include minor or tempo rary bleeding, bruising, swelling, and/ or redness or other discolorations. Fading or loss of pigment may occur. Unevenness in the design may occur due to swelling. Secondary infection in the area of the procedure may occur, however if all after care instructions (that are provided) are followed it is rare.

Initial

I have informed Cori Simons of any and all health problems

Initial

I acknowledge that complications including infection are always possible as a result of cosmetic tattoo procedures, particularly in the event of my post-procedural instructions are not followed.

Initial

I acknowledge that is not reasonably possible to determine whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risks that such a reaction although rare, is possible. I have informed Cori Simons of any existing problems.

Initial

I REQUEST a patch test (requires rescheduling)I DECLINDED a patch test

It has been explained to me that immediately after the procedure is completed, the color will appear dark and the design will appear to be thicker. It has also been explained to me that within a short period of time (usually 6-10 days) during the healing process , the color will lighten/soften and the design/ procedure will heal thinner that it looked the day it was performed.

Initial

Results WILL appear softer as the treated area heals. The area/s treated WILL NOT look as DEFINED or as BOLD as immediately after the procedure. My skin type and treatment of the area will determine my healed results.

Initial

I understand that if I have oily/severely oily skin the pigment will heal/appear much softer and can softer due to the over production of oil. The pigment WILL fade quicker. I accept this risk and would like to proceed.

Initial

I acknowledge and understand that pigment implanted on darker skin types (ie Indian, African American, Pilipino, Hispanic etc) the pigment will appear softer and blend more with you own skins melanin and will not appear as bold or defined as on lighter skin types.

Initial

I acknowledge that a touchup session may be needed to insure proper color retention. The touchup session is not included and is a $50 tray fee within 6 months of your initial session.

Initial

I acknowledge that hyper-pigmentation (darkening of the skin) or hypo-pigmentation (absence of color in the skin), or scarring is a possibility as a result of my body’s reaction to to the skin being broken during the procedure. I realize that my body is unique and that Cori Simons cannot predict how my body will react as a result of this procedure

Initial

Frequent tanning and sun exposure WILL heal darker (ashy undertones) and WILL fade the pigment quicker. It is recommended to NOT have a tan/burn (30 days before/after) on your face at the time of your procedure.

Initial

I acknowledge that the procedure will result in a permanent change in my appearance and that no representations have been made to me as to the ability to later change or remove the results.

Initial

Alopecia Clients or Clients that shave their brows, due to the change in the skins texture, pigments may heal more powdered.

Initial

I understand that future laser treatments, plastic surgery, implants, injections, and other skin altering procedures may alter and degrade my cosmetic tattoo procedures. I further understand that such changes are NOT the responsibility of Cori Simons, and such changes in my appearance may NOT be correctable through further cosmetic tattoo procedures.

Initial

I understand that tattoos may cause MRI (Magnetic Response Imaging) artifacts and that is a 1%-2% chance of a reaction. Within that 1%-2% for almost all there will be a warming and/or tingling sensation in the tattooed area the MRI due to the iron oxide properties of some pigments. It is understood that I should advise my physician that I do have permanent cosmetics (a tattoo) in the event an MRI procedure is prescribed.

Initial

I authorize Cori Simons to obtain pre-procedural and post-procedural pictures, and give her permis-sion to use such pictures for publication and/or teaching purposes as she chooses

Initial

I authorize Cori Simons to obtain pre-procedural and post-procedural pictures, and give her permission to use such pictures for publication and/or teaching purposes as she chooses. (Photos are taken for liability purposes but will not be shared without your permission)

Full FaceHalf FaceEye and Brow Only

I acknowledge the receipt of written instructions advising me of the proper care of my procedure and ointment will be provided by Cori Simons. I understand the absolutely necessity for following these instructions.

Initial

I understand that cosmetic tattooing is an art form and NOT an exact science, and I acknowl-edge that NO guarantees have been made to me as the result of this procedure. Some skin types will not accept or heal pigment in a consistent manner. Your skin and how well you take care of your procedure will determine your result. I realize that my body and my skin is unique and that Cori Simons cannot in any way predict how your skin may react to the procedure or how it may or may not accept color. I also realize that Cori Simons cannot predict how many visits it will take to complete my procedure.

Initial

The fee for the cosmetic tattoo procedures have been explained to me including the initial procedure fee, touchup fees, and maintenance fees. These fees are understood and agreed upon. I understand the total fee for services rendered is due upon completion of the initial procedure and that WILL BE separate fees for any touchup/ follow-up work.

Initial

I accept full responsibility for determine the color, shape, and position of the pigments that will be applied, I understand the actual healed color of the pigment applied will be modified slightly due to my own unique skin undertones.

Initial

I acknowledge that this procedure will fade and this fading can alter the original pigment color. This fading determines that is time for a touchup.

Initial

Due to the fact your approval is obtained prior to final selection of color to be implanted and design application that all facts about cosmetic tattooing have either been disclosed or discussed with you, and that you have been given full opportunity to have any and all questions answered, Cori Simons employs a NO REFUND policy.

Initial

Cori Simons has the right to refuse service to anyone at any time for any reason.

Initial

I agree that if I had permanent cosmetics performed previously by another technician, I will not hold Cori Simons responsible for future allergic reactions or contraindications.

Initial

This contract is to remain in effect for as long as I remain a client of Cori Simons and all its contents apply whenever work is being performed on myself by Cori Simons. It is my responsibility to inform Cori Simons if any changes have occurred in my medical history.

Initial

I have read and understand the contents of each paragraph above. I have received no unrealistic warranties or guarantees with respect to the benefits to be realized from, or consequences of the aforementioned procedure.

Initial

*I am over the age of 18, and not under the influence of any drugs or alcohol.

Initial

I acknowledge by signing this consent form, have been given full opportunity to ask any and all questions about cosmetic tattooing pro-cedures, its process, and the risks involved from Cori Simons. The decision to have cosmetic tattooing procedures performed is my own and I understand all risks involved, therefore releasing Cori Simons of any and all legal liability. Cori Simons is an artist, a highly trained, experienced and skilled artist and makes no claims to be anything more. Permanent makeup/ cosmetic tattooing is not a med-ical procedure but an art form, the art of tattooing. NO REFUNDS... NO EXCEPTIONS.

Client Name (signature).

Date

Boise Brows Permanent Cosmetics Information and Consent Forms

Boise Brows Informed Consent