Ombré powder brows Consent Form

Name*

First NameLast Name

Date of Birth*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

Are you on any blood thinning medications?*

YesNo

Do you have any autoimmune disorders?*

YesNo

Are you pregnant or breast feeding?*

YesNo

Have you had alcohol or caffeine in the past 24 hours?*

YesNo

I have received after care information and I’m fully aware of the aftercare procedures. I fully understand the information provided above & confirm that all information provided by me is correct and truthful.*

Date*

What is "Permanent Makeup"?

"Permanent Makeup" is the procedure of inserting pigment into the basement membrane layer of the skin, via a blade(s) or needle(s). The basement membrane is between the epidermis (superficial layer) and the dermis (deepest layer). Because this procedure is more superficial than a normal tattoo, it is considered semi-permanent, lasting from 1-3 years for eyebrows. As your skin naturally exfoliates over time, the permanent makeup will inevitably fade and may require touch-up sessions for maintenance.

Risks

With the injection of pigment into the skin, the skin will open and there is a very small degree of risk for infection, although exceedingly uncommon. Every tool is pre-sterilized, disposable, and disposed of after use. Cross-contamination procedures are strictly followed. To avoid the risk of infection during healing process, it is important to strictly adhere to the aftercare instructions provided to you.

I have been informed and I understand that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit.

Initials*

Expectations for Results

Results vary from client to client. Results vary due to each client's individual health, lifestyle and skin type. Results will likely fade 30 - 40% by the end of the complete healing process (approximately 30 days). In very rare cases, the pigment may diffuse in the skin. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years.

I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeated procedure. The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, as well as adherence to pre and post procedure after care. Upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-4 days. You may resume your normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed. I have been advised that true results will be seen 1 month after the procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given. I understand that there will no refunds given once the procedure has been completed.

Initials*

Allergies

I understand that topical anesthetic is used and may contain lidocaine or other similar active ingredients. There may be nickel in tattoo needles and certain pigments, and may trigger allergic reactions in rare cases. I release Ivonne Padilla and Theory of Beauty Studio from all liability if I develop an allergic reaction to pigments, anesthetic, needles and any products used during the procedure. If an unforeseen condition arises in the course of the procedure, I authorize my artist to use her professional judgment to decide what she feels is necessary under the given circumstances.

Initials*

Photo Consent

By initialing, I consent to the use of my photos for the purpose of marketing. My pictures may appear in print or online. My photo may also be saved for documentation with my confidential client file.

Initials

Final Consent

I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing, and desire to receive the indicated permanent pigmentation procedure. 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 the procedure done at this time. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed has been explained to me. I acknowledge and agree with everything I have read thus far, and am willing and ready to continue with the permanent makeup procedure.

I certify that my artist has presented to me the brow design, shape, placement and color prior to application today and that I have approved of the presented design, shape, placement and color prior to application.

I consent to the application of the agreed upon design, shape, placement and color.

By signing this consent form I certify that I knowingly and voluntarily release Ivonne Padilla and Theory of Beauty Studio from any and all claims for damages of personal injury arising from this appointment.

Signature*

Date*

Brief Health History

Informed Client Consent