BOMB BROWS CONSENT AND MEDICAL FORMS

This form is designed to give information needed to make an informed choice of whether or not to undergo microblading, Ombre, lip blush, eye lash enhancement, eyeliner, saline removal, or Semi-Permanent Makeup application. It is the client's responsibility to research these services & conduct their due diligence before receiving permanent cosmetics. If you have any questions please don't hesitate to ask.

Although Eyebrow Microblading and Semi-Permanent Makeup application is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent, can have long lasting results.

All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are strictly adhered to.

Generally the results are excellent. However, a perfect result is not a realistic expectation. It is usual and advised to expect a touch up after healing is completed.

Initially the color the will appear more vibrant or darker compared to the end result. Within 5-7 days the color will fade 40-50%, soften, and look more natural. The pigments semi-permanent and will fade over time. Additional touch ups required 8-12 weeks post initial services, and also color boost 1-3 years following or as needed. Aftercare instructions and expectations are provided to each client via email and text.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Take Photo*

Photo Release- I acknowledge that my photos will be taken before, during, and after services for both insurance liability and advertising needs of Bomb Brows LLC.

How did you learn about us?*

Signature*

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CREDIT CARD POLICY: A $75 deposit per service is required to book your appointment. We don’t want to waste anyone’s time. All deposits are non-refundable to ensure that you are serious about booking your appointment. Deposit requests are automatically charged after you complete the consent forms using your card on file to secure your appointment.Your deposit will be applied towards your service total during checkout. It will be lost if you fail to give an adequate cancellation notice or fail to show up to your appointment.*

DEPOSIT POLICY: These are non-refundable! Deposits count towards the day of service total and are required to be paid to confirm the appointment. For no-shows or late cancellations, you will need to forfeit the deposit. No exceptions. This can also be transferred if you reschedule outside of the 72-hour window of appointment time.*

LATE POLICY: If you are running late please contact us ahead of time. We allow a 15-minute grace period. Anything beyond that is considered an automatic cancellation, you will be required to reschedule your appointment and you will be charged 100% of the service fee as stated in the cancellation policy below.*

CANCELLATION POLICY: I ask that you please value and respect my time. Should you have to cancel, please provide me with 72 hours' notice for any appointment. This enables me to contact and book other clients on my waiting list or to post your last-minute cancellation online.Appointments canceled, rescheduled, or altered less than 72 hours will be charged 50% of their service. No shows will be charged 100% of the service value. Any notice past 15 minutes of your appointment is considered a no-show.I understand that sometimes life can happen. These policies are not set to deter you from receiving your service. Rather, to gain your understanding and empathy that as a business, I value my client’s time and trust and rely on my clients to arrive at their appointments on time.*

Please answer the following question with full honesty and accuracy.

Are you taking any kind of medications within the last 6 months?*

YesNo

Have you had permanent make up before? If yes, for what and when was your last appointment?

Is it a prescribed medications?*

YesNo

Please indicate the medications that you're currently taking*

Do you have any known allergies to food, medicine, or cosmetic products?*

YesNo

If yes, what are your allergies?

Are you pregnant? Services will not performed on pregnant women.*

YesNo

Aftercare instructions have been explained to me and a writer copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email you. (You will receive the writer copy at your appointment)Initials*

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

I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas, They will alter the color and cause premature exfoliation of the pigment.Initials*

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

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

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

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

I understand that implanted pigment color can slightly changed or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 8-12 weeks.Initials*

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

I have been advised that a touch-up session is required as all offerings are a minimum of two sessions- 8-12 week touch up is mandatory to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Results cannot be guaranteed. Clients who skip touch ups are opting out of at least 50% of required process And artist cannot correct or provide any changes for clients who refuse touchup. Touch-ups much be completed within 8-12 weeks of initial procedure.Initials*

I have been quoted the cost of my selected treatment and the cost of the touch-up. Touch-ups must be completed within 8-12 weeks of initial procedure to be considered a touch-up. There are NO REFUNDS. Initials*

I understand that ALL SALES ARE FINAL and there is a strict NO REFUND policy. This includes any and all deposits. I also understand that Bomb Brows LLC reserves the right to refuse service to any client due to not being a good fit or failing to follow proper aftercare procedures.Initials*

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 this procedure (s). 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 an apprentice of Bomb Brows as my Technician to perform my permanent cosmetics or removal services. It is my responsibility to perform research on services I book and will ask questions on anything I do not understand prior to receiving services. Initials*

Please read all the sentences and sign the agreement. I authorized BOMB BROWS LLC to perform a cosmetic enhancement service. I was informed that permanent and semi-permanent cosmetic enhancement is the same as the process of tattoo and it is an advanced version of it. I completely understand that in some rare cases, allergic reactions may occur even after my disclosure of all known allergy history I may have due to the pigment. I accept all the responsibility, and I fully understand the health risk of it. I accept that the pigment might fade before or after 3 years, and may leave a mark or residue of color. I understand the possible side effects of the procedure and will be able to diagnose if it is normal or not. I confirm that I do not have any physical, medical, and mental conditions that might get conflict with the procedure. I confirm that I will strictly follow the pre and post-procedure instructions given to me. I confirm that all information I entered in this form is accurate and true to the best of my knowledge. I hereby certify and give this clinic my full consent to perform the necessary procedure. By signing below, I confirm that I have read and understood the statements above.

Signature*

Clear

Date Signed*

Date

Service/Services Being Requested:

Please provide a full face photo, with adequate lighting and position the camera straight on to the face- no side angles.No make up.*

Client Medical History

EMERGENCY CONTACT INFORMATION - PLEASE LIST YOUR EMERGENCY CONTACT BELOW

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

CLIENT MEDICAL HISTORY FORM

DO YOU CURRENTLY/ HAVE YOU EVER HAD:

HISTORY OF MRSA*

YESNO

BOTOX*

YESNO

DIABETIES*

YESNO

Have you had Hepatitis A B C D within the last 12 months?*

YESNO

JAUNDICE WITHIN LAST 12 MONTHS?*

YESNO

FOREHEAD/BROW LIFT?*

YESNO

EASY BLEEDING? OR ANY MEDICAL CONDITION THAT CAUSES EXCESSIVE BLEEDING?*

YESNO

FACELIFT?*

YESNO

ALCOHOLISM?*

YESNO

ABNORMAL HEART CONDITION?*

YESNO

TAKE ANY MEDICATION BEFORE DENTAL WORK?*

YESNO

CHEMICAL PEEL WITHIN LAST 90 DAYS?*

YESNO

CURRENTLY PREGNANT OR BREASTFEEDING?*

YESNO

BROW OR LASH TINT OR LAMINATION?*

YESNO

AUTOIMMUNE DISODER?*

YESNO

OILY SKIN?*

YESNO

TAKE/TAKEN ACCUTANE OR ACNE TREATMENT WITHIN LAST 12 MONTHS? TOPICAL OR ORAL*

YESNO

CHEMOTHERAPY OR RADIATION?*

YESNONOT WITHIN LAST 12 MONTHS AND CAN PROVIDE DOCTORS APPROVAL LETTER

TANNING BOOTH OR PROLONGED SUN EXPOSURE WITHIN THE LAST 4 WEEKS? SUNBURN?*

YESNO

TUMORS/GROWTH/CYSTS?*

YESNO

EVER HAD DIFFICULTY NUBING FOR DENTAL WORK OR OTHER COSMETIC PROCEDURES?*

YESNO

TAKING/RECENTLY TAKEN BLOOD THINNERS-Aspirin, Ibuprofen, Alcohol, Coumadin, Fish Oil, etc*

YESNO

ALLERGIC REACTION TO ANY medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.*

YESNO

ALLERGIES TO METALS/FOOD/DYES? PLEASE LIST BELOW*

YESNO

LIST OF ALLERGIES

DO YOU USE ANY SKIN CARE PRODUCTIONS THAT INCLUDE Retin-A, Glycolic Acid, or Alpha Hydroxyl*

YESNO

LASH GROWTH OR BROW GROWTH SERUM WITHIN THE LAST 6 WEEKS/ 6 WEEKS PRIOR TO APPOINTMENT?*

YESNO

Are you prone to, have or had in the past hyper pigmentation, hypo pigmentation or keloids?

YesNoI’m not sure

PLEASE LIST ANY CURRENT MEDICATION OR SUPPLEMENTS YOU ARE TAKING / HAVE TAKEN WITHIN THE LAST 30 DAYS:*

POSSIBLE RISKS, HAZARDS, or COMPLICATIONS
PAIN: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others.
INFECTION: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the area. See "after care" sheet for instructions on at home care.
UNEVEN PIGMENTATION: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance.
ASYMMETRY: Every effort will be made to avoid asymmetry, but our faces are not symmetrical so adjustments may be needed during the follow up session to current any unevenness.
EXCESSIVE SWELLING or BRUISING: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don't bruise or swell at all.
ANESTHETICS: Topical anesthetics are used to numb the area to be tattooed. lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now.
MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI Technician of any tattoos or permanent cosmetics.

I understand that upon submitting this form, I will AUTOMATICALLY be chared a deposit fee of $75 PER SERVICE using the credit card on file. That booking fee must be paid prior to my appointment being confirmed. This booking fee will go towards the price of my service. Failure to pay it will result in my appointment being declined. I understand this booking fee is non-refundable but can be transferable as needed- or with proper notice of at least 72 hours. I understand all sales are final and NO REFUNDS will be given.

Name*

First NameLast Name

Signature*

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Notice* It is generally reccomended all clients consultant with their Doctor prior to recieveing any permanent or semi-permanent cosmetic services.

Last 4 digits of card on file

Expiration date of card on file mm/dd/yyyy

Signature

Clear

Full Name

First NameLast Name

BOMB BROWS Permanent Makeup Client Information Form

Driver's License Photo

Credit Card Authorization