The Beauty Bar on State Consent & Medical Form

The Beauty Bar on State Consent Form
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Cosmetic Procedure*
Patch Test Process*
STATEMENT OF CONSENT AND RECITAL FOR PERMANENT MAKEUP

Skip to next section if booking other service.

I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.

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

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

I understand that successful lip color saturation can NOT be guaranteed due to hidden scar tissue.

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

I accept the responsibility of explaining to you my desire for specific colors, shape, and position for any procedure done today.

I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond my control and I will need to maintain the color with future applications and a touch-up session within 60 days.

I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have the possibility of complications during and/or following the procedure(s) such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.

I have been told the cost of today's appointment which includes one (1) touch up after 30 days and within 60 days. After 60 days a fee will apply and there will be no refunds for the elected procedure(s).

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 the procedure(s) and 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 I authorize my Permanent Makeup Artist to perform on my body the Eyebrow procedure on me today.
Signature*

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Date Signed

MonthDayYear
Date
Medical History Form
Do you presently have or previously had any of the following:*

PregnantBreastfeedingHistory of MRSADiabetesDrug AllergiesAlopeciaPrevious Permanent MakeupCold SoresHepatitis A, B, C, DHIVBlood ThinnersTrichotillomaniaEasy BleedingAlcohol/Drugs in last 24 hoursChemical PeelAccutane UseBotox in last monthChemo or radiation in last 6 monthsRemoval for cosmetic tattooOily SkinTan in tanning boothCurrently Wearing Eyelash ExtensionsOver 18 years oldPsoriasis or EczemaUse of glycolic acid or Retin-AAny allergic reaction to Lidocaine, Dermacaine, Epinephrine, Benzyl Alcohol, Vitamin E Acetate or Propylene GlycolAny current use of antibiotics for infection
Provide any necessary notes/information from questions above.
Photography Release Consent

We would like your permission to use these photos for advertising. For example in portfolios, online and in print ads, etc. Your consent is necessary regarding this. Please choose and indicate with your signature if you would like your photos used or not used in advertising.
Signature

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Lash Extension Client Liability Waiver
I UNDERSTAND THAT THERE ARE RISKS ASSOCIATED WITH HAVING ARTIFICIAL EYELASHES APPLIED TO AND/OR REMOVED FROM MY NATURAL LASHES I UNDERSTAND THAT AS PART OF THE PROCEDURE, EYE IRRITATION, PAIN, ITCHING DISCOMFORT AND IN RARE CASES EYE INFECTION MAY OCCUR. I UNDERSTAND AND AGREE THAT IF I EXPERIENCE ANY OF THESE ISSUES WITH MY LASHES I WILL CONTACT MY TECHNICIAN AND HAVE THE EYELASH EXTENSIONS REMOVED IMMEDIATELY AND CONSULT A PHYSICIAN AT MY OWN EXPENSE. I UNDERSTAND THAT EVEN THOUGH THE TECHNICIAN MAY APPLY AND REMOVE THE EYELASH EXTENSIONS PROPERLY, THAT ADHESIVE MATERIAL MAY BECOME DISLODGED DURING OR AFTER THE PROCEDURE, WHICH MAY IRRITATE MY EYES OR REQUIRE FURTHER FOLLOW UP CARE. I UNDERSTAND AND AGREE TO FOLLOW THE AFTERCARE INSTRUCTIONS PROVIDED BY MY TECHNICIAN. FAILURE TO FOLLOW THE AFTERCARE INSTRUCTIONS MAY CAUSE THE EYELASH EXTENSIONS TO FALL OUT. I UNDERSTAND THAT IN ORDER TO HAVE THE EYELASH EXTENSIONS APPLIED TO MY EYELASHES I WILL NEED TO KEEP MY EYES CLOSED FOR DURATION OF 60-180 MINUTES DURING THE PROCEDURE. I ALSO UNDERSTAND THAT I WILL NEED TO BE LYING IN A RECLINED POSITION. ANY MEDICAL CONDITIONS THAT MIGHT BE AGGRAVATED BY LYING STILL FOR A PROLONGED PERIOD OF TIME MAY MEAN THAT I WILL NOT BE ABLE TO HAVE THE PROCEDURE PERFORMED ON MY EYES. THIS AGREEMENT WILL REMAIN IN EFFECT FOR THIS PROCEDURE AND ALL FUTURE PROCEDURES CONDUCTED BY MY TECHNICIAN. I UNDERSTAND THAT THIS AGREEMENT IS BINDING AND THAT I HAVE READ AND FULLY UNDERSTAND ALL INFORMATION ABOVE. I RELEASE MY TECHNICIAN LASH GYAL FROM ALL LIABILITY ASSOSIATED WITH THIS PROCEDURE. THERE ARE NO GUARANTEES FOR THE BONDING TIME LENGTH OF THE EYELASH EXTENSIONS. LASH GYAL IS NOT RESPONSIBLE FOR ANY TECHNICIAN ERRORS. I UNDERSTAND THAT I HAVE BEEN ADVISED TO FOLLOW THE AFTERCARE PROTOCOL FROM MY TECHNICIAN SO AS TO AVOID ANY DISCOMFORT OR ADVERSE SIDE EFFECTS AFTER THE PROCEDURE HAS BEEN COMPLETED.
Proof of ID- Please provide proof of ID for all permanent makeup and tattoo service

The Beauty Bar on State Consent Form

Medical History Form

Lash Extension Client Liability Waiver