HEALTH HISTORY
NAME
*
First Name
Last Name
BIRTHDAY
*
-
Month
-
Day
Year
Enter your birthday
EMAIL
*
example@example.com
PHONE NUMBER
*
-
Area Code
Phone Number
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HOW DID YOU HEAR ABOUT US?
*
Google
Facebook
Instagram
Yelp
Friend
Other
CLIENT HISTORY
ARE YOU UNDER THE CARE OF A PHYSICIAN?
*
Yes
No
IF SO, WHY?
PHYSICIAN'S NAME
DO YOU TAKE ANTIBIOTICS WHEN GOING TO THE DENTIST?
*
Yes
No
IF YES, WHY?
DO YOU SUFFER FRO ANY OF THE FOLLOWING?
*
Allergies
Moles or freckles at procedure site
Hepatitis
Heart problems
Hemophilia
Diabetes
Skin problems
Scarring
Eye problems
Epilepsy
TB
Asthma
HIV/AIDS
MRSA/Staph infections
Fainting/diziness
None
Other
ARE YOU ON BLOOD THINNERS?
*
Yes
No
ARE YOU TAKING ANY OTHER MEDICATION?
*
Yes
No
IF YES, WHAT?
ARE YOU PREGNANT OR NURSING?
*
Yes
No
DO YOU WEAR CONTACT LENSES?
*
Yes
No
HAVE YOU HAD ANY PREVIOUS EYEBROW TATTOOS DONE BY ANOTHER ARTIST? IF YES, THIS IS CONSIDERED A CORRECTION BROW WITH A SLIGHT EXTRA CHARGE
*
Yes
No
PROCEDURE TO BE PREFORMED:
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Ombré brows
Combo brows
Microblading
Correction (If worked on previously by another artist)
Touch up of my own work
Removal/Lightening
Lash Liner
Lip Blush
Microshading
SMP
Tiny Tattoo
FOR EYELINER ONLY...
DO YOU WEAR EYELASH EXTENSIONS?
*
Yes (If so please remove prior to your appointment)
No
HAVE YOU USED LASH SERUM IN THE LAST 3-6 MONTHS??
*
Yes (If yes, please reschedule)
No
CONSENT FORM
I specifically acknowledge that I have been advised of the matters set forth below and agree as follows
*
Yes
No
I acknowledge that obtaining permanent makeup or removal is my choice alone. The application of permanent makeup/removal will result in a permanent change of my appearance and that needles and/or ink will go into my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent makeup to the original condition, and it is very costly to remove.
*
Yes
No
I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reactions to latex or antibiotics, hemophilia or other bleeding disorders. I do not have cardiac valve disease or suffer from any heart condition or take medication that thins my blood. If I suffer from hepatitis or other risk factors for bloodborne pathogen exposure or any other communicable disease, I have informed the technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my tattoo/wound.
*
Agree
Disagree
I do not suffer from any medical or skin conditions such as but not limited to; keloid or hypertrophic scarring, psoriasis at the site of the permanent makeup/removal, or any open wounds or lesions at the site of the tattoo. I do not have a history of medication use or currently using medication including being prescribed antibiotics prior to dental or surgical procedures.
*
Agree
Disagree
I have advised the technician of any allergies to latex gloves, soaps or medications. I acknowledge it is not reasonably possible for the technician to determine whether I might have an allergic reaction to the permanent makeup or removal process and further acknowledge that such reaction is possible.
*
Yes
No
I have truthfully represented to the technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo or removal at this time.
*
Yes
No
I acknowledge infection is always possible as a result of permanent makeup application or removal, and I agree to follow all suggested instructions concerning the care of the permanent makeup site while it is healing.
*
Yes
No
I understand I will have permanent makeup or removal using appropriate instruments and sterilization techniques. I understand that the permanent makeup site usually takes 4 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the technician (Carly), all employees, contractors and the management of the permanent makeup/removal studio from any and all claims of negligence, damages or legal actions arising from or connected in anyway with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility or the decisions made consenting to this permanent procedure.
*
Yes
I am aware that permanent cosmetic inks, dyes and pigments have not been approved by the FDA and that the health consequences of using these products are unknown.
*
Yes
No
I acknowledge and give consent to this permanent makeup studio to use images of my tattoos for marketing. I consent to allowing photos and videos taken of me before, during and after the procedure.
*
Yes
No
Brows by Carly is also a training academy and occasionally there are students shadowing the session for educational purposes. I acknowledge and give consent to have students present at my appointment and watch the procedure. (Only for models)
*
Agree
Disagree
I acknowledge that my semi permanent tattoo can (but isn't likely to) fade, fan, spread and/or migrate.
*
Agree
Disagree
I acknowledge that the results of my permanent makeup or removal service varies on several factors such as skin type, skin care, sun exposure etc and that is my full responsibility to follow the aftercare instructions provided in order to achieve the best results. (Does not apply to removal clients)
*
Yes
No
I acknowledge that the technician has the right to refuse service to any client who she deems unfit for the procedure.
*
Yes
No
I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent makeup or removal from Carly and that all of my questions have been answered to my full and total satisfaction.
*
Yes
No
I have been sent the aftercare document and let Carly know that I understand the aftercare information given. I fully understand the information provided above and confirm the information I provided is correct. (Sent 24 hrs before appt)
*
Yes
No
I understand that this could be a two step process and I might a touch up after 4-6 weeks to achieve desired color/darkness. I understand that my eyebrows/liner/lips will heal up to 60% lighter because this is a semi permanent tattoo. The touch up is a separate fee ($149) and I am required to place a deposit to book this appointment. I also understand that results very based on skin type and health condition. (Does not apply to removal clients)
*
Yes
I understand that **ALL SERVICES AND DEPOSITS/BOOKING FEES ARE NON REFUNDABLE**
*
Yes
UPLOAD A PHOTO OF YOUR ID, PASSPORT, OR BIRTH CERTIFICATE
*
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SIGNATURE
*
The Parties covenant and agree that in no event, and at no time during the Term or at any time thereafter, shall either of them disparage, denigrate, slander, libel or otherwise defame the other or the other’s businesses, services, properties or assets, or employees, personnel, agents, or representatives.
*
I agree
SUBMIT
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