Kristin Cara Brows (Medical History & Consent Form)

FULL NAME*

BIRTHDAY*

EMAIL ADDRESS*

example@example.com

CELL NUMBER*

HOW DID YOU HEAR ABOUT US?*

REFERRAL NAME (IF APPLICABLE)

EMERGENCY CONTACT/NUMBER

Do you have an autoimmune disease (DIABETES, LUPUS ETC.)?*

YesNo

YesNoNot Applicable

YesNo

Does your skin swell easily?*

YesNo

Ever tested positive for HIV and/or Hepatitis (A,B,C,D) and or TB*

History of MRSA?*

YesNo

Any allergies? (Lidocaine, Nickel, Dyes, Coconut etc.)*

Do you have oily skin?*

YesNo

Cancer? *

Currently on Chemotherapy/Radiation? When was last treatment for either?*

Any history of Keloid Scarring?*

Face/Brow or Forehead Lift? If Yes, how long ago?*

Are you currently taking any medications? (immunosuppressant, anti-inflammatory / steroid or blood thinner)?*

Any other medical conditions or concerns not listed?*

Do you have epilepsy or a history of dizziness or fainting?*

Have you ever been advised to take antibiotics prior to dental surgery?*

Client Signature*

Date*

Date

*Pain: There is a possibility of pain or discomfort even after topical anaesthetic has been used

*Infection: Although rare, there is a risk of infection. Areas treated must be kept clean. If you ever suspect signs of infection please seek medical attention immediately.

*Uneven Pigmentation: This can result from poor healing, infection or other causes beyond Kristin Cara Brow's control

*Asymmetry: Every effort is taken to avoid asymmetry but our faces are not symmetrical so adjustments may be needed at the mandatory 4-8 week touch up.

*Allergic Reaction: There is always a possibility of an allergic reaction to the pigment, blade or anesthetic used. You may take a 24 hour patch test to determine prior to treatment.

*Unpleasant Results: I understand that tattooing is permanent and choosing to have it removed can be costly and cause scarring. The brow tattoo services that are offered at Kristin Cara Brows are "Semi-Pemanent".

* Aftercare instructions have been explained and I fully understand them I fully understand possible risks and assume any and all liability associated with this procedure

* I understand this service is not complete without a 4-8 week mandatory touch-up that may come with an additional cost if I do not come within the required time frame for the initial touch-up appointment.

* It has been recommended to perform a patch test if I am known to have allergies to metals (nickel), pigments and/or dyes, prior to any Micro-pigmentation procedure; however, I do not want a patch test against recommendation of the technician and I am waiving the patch test Any allergies to any numbing agents including any "CAIN" ingredients

* I am not under the influence of drugs or alcohol and I was given precare instructions to not have any caffeine or alcohol in my system 24 hrs prior to my appointment as that would create blood to thin and cause excess bleeding during the procedure which will result in poor retention and results.

* I am 18 years of age or older

* I am aware that there will be before & after photos taken and that they may be used for marketing & advertising purposes and posted online for portfolio work.

* I am fully aware of the risks of tattooing including, but not limited to; infection, scarring, difficulties in detecting melanoma, an allergic reaction. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with the tattoo application and assume any and all risks that may arise from tattooing.

Yes, I agree.

I, the client herein signed, certify that I have read and had explained to me and fully understand the above Waiver and Release Form. I certify that I have consulted with the Permanent Makeup Artist and have read all applicable literature given to me. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this waiver and release form for myself. I, the undersigned client, acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time. I, the client herein signed, for the purposes of documentation, hereby consent to “before and after” photographs.*

Yes, I agree.

I, the client herein signed, hereby give the absolute right and unrestricted permission to take, use, and display photographic images of me, through any form of media (print, electronic, broadcast, or otherwise) at any location for art, advertising, media release new articles, marketing, publicity, archival, or any other lawful purpose. I waive any right to royalties or other compensation arising from or related use of photographic images of me.*

Yes, I agree.

Signature*

Date*

Date

Microblading + Microshading + Combo Brows

MEDICAL HISTORY

CONSENT FORM