Consent-Forms-for-online-Acuity

Pre Procedure Form

Contraindications for procedure
- pregnant or nursing
- chemotherapy and radiation for treatments – prophylactic chemotherapy is certainly safe to proceed
- Active dermatologic disorders, I.E.rosacea, eczema, psoriasis
- eyelash extensions must be removed prior to eyeliner
- Sick with the flu or fever
Require Waiting Periods
- Lasik or cataract surgery in one month prior and wait three months postop
- Latisse – two weeks sauce
- Botox or disport – one day since they cannot lie flat for at least five hours
- fillers i.e. Juvéderm, so, Voluma, sculpture, etc. – one week
- fat transfer in lips – wait one month for swelling to subside
- Accutane folders in one year half dose or prophylactic does not need medical clearance
- suntan skin- one month
- Retinol, glycolic acid, vitamin C peels – four weeks
- laser -8 weeks
- IPL – 1 week
- shingle shot- 1 month
- laser that removed old permanent make up – 8 weeks
Require Medical Clearance/Pre-Medication
- heart valves, stents, pacemakers, rheumatic fever – medical clearance and pre-medication
- organ transplants – medical clearance and pre-medication
- Joint replacements – medical clearance and pre-medication
- Insulin-dependent diabetic/medical clearance and pre-medication
- Fever blister history – pre-medication
- Seizures - medical clearance
- lead thinners, steroids – medical clearance
- Eye disease (I.e. glaucoma or aggrieves disease) - medical clearance
- lupus- Medical clearance and pre-medication
- Blepharitis - Medical clearance

Name*

First NameLast Name
Date*

MonthDayYear
Date
Date of Birth *

MonthDayYear
Date
Age*
Please provide proof of age and identity for the State of NJ Board Of Health...Front of Drivers Licence for proof of age or goverment issued photo ID

Cancelof
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Emergency Contact Person*
Phone*
Physicians Name, Address, Phone number and specialty.*
List of all medication’s you’re presently taking, milligram or microgram, how many each day, why it was prescribed to you.*
List of all medications you took in the last six months that you are no longer taking : milligram or microgram, how many each day, why it was prescribed to you.*
Signature *

Clear

Photo Release

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.
Type a question*

I do give permission to use my full face for advertising purposesI give permission to use my partial face for advertising PurposesI do not give permission to use my pictures for advertising purposesOther
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

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 areas. See the "After Care" sheet for instruction

Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven

Asymmetry: Every effort will be made to avoid asymmetry, but out faces our are not symmetrical so adjustments may be needed during the follow-up session to correct

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 makeup.

The alternative to these possibilities is to use traditional cosmetics and NOT undergo the Semi-Permanent Eyebrow procedure.
Special requests, concerns or remarks for the Artist
I have read and understand all of the above information regarding permanent makeup and Microblading and understand *

Clear
Name

First NameLast Name
Date*

MonthDayYear
Date

Patch Test Consent Form

Patch testing involves placing small amounts of substance against the skin and fixing them in place for 48 to 72 hours. The testing site is then monitored for local reaction. Potential adverse events include rush at this site, infection, or delayed skin reactions. There is a possibility of an allergic reaction to pigments. Pigments continents are:Iron oxide, titanium dioxide, isopropyl alcohol, glycerin, ethanol, and distilled water.A patch test is advisable however it does not ensure a client will not have an allergic reaction.
I Waive The Patch Test: Allergic Reaction: Although an allergy is unusual, there is always a possibility of an unknown allergy to the pigments and materials used during procedure. I am waiving my rights to a patch test*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
I consent the patch test: (optional) I received a positive test on the date below the patch test has been received and it releases Browhaus Studio LLC from any liability related to any allergies or other reactions to apply tattoo, permanent make up pigments. I have been informed that reactions can occur at any time in the future. Sun exposure can also cause a reaction with pigments/colors

Clear

Microblading Aftercare Instructions

It is essential that you follow these instructions after your Microblading session.
Day One (Day of treatment): Wait 1-2 hours and let the wounds weep lymph. After 2 hours you must wipe off the lymph with a moistened cotton pad, Pat dry, then apply a thin layer of Aquaphor or The after care provided by your practitioner with a cotton swab. Do this every 2 hours until bed.

At night wash the treated area with warm water and mild soap like Cetaphil. Wash your hands with a disinfectant soap before washing your eyebrows and/or applying the post- procedure ointment

NOTE: Too much Aquaphor will cause the pigment to scab. Aquaphor is available in the skin care section of any drug store.

Day Two - Nine: Repeat the wiping of the brows at least 2 times a day. At night wash the treated area with warm water and mild soap like Cetaphil. Wash your hands with a disinfectant soap before washing your eyebrows and/or applying the post-care cream.

Day 3 - wake up rinse with cold temp at water, pat dry, apply ointment. Be sure to apply a very thin coating of ointment as needed throughout the day through the next four weeks of your healing process. Continue to wash at night with a mild soap such as Cetaphil And refrain from using any existing skin care products that you may Typically use at home.

The following must be avoided during all nine days post-microblading procedure:

Sweating. It is recommended not to sweat for the first 10 days after the procedure. Sweat is salt and can prematurely fade the treated area. Practicing sports Swimming Hot sauna, hot bath, or Jacuzzi Sun tanning or salon tanning. Absolutely No Sun, sweating, or tanning prior to the procedure or after the procedure for 2 weeks. Do not have a tan/sunburn on your face prior to your procedure. The tan will exfoliate taking color with it as it fades. Any laser or chemical treatments or peelings, and/or any creams containing Retin-A or Glycolic Acid on the face or neck Picking, peeling, or scratching of the micro pigmented area in order to avoid scarring of the area or removal of the pigment Performing tasks related to heavy household cleaning such as garage or basement cleaning where there is a lot of airborne debris Spicy foods Smoking Drinking alcohol in excess, as it may lead to slow healing of wounds Driving in open air vehicles such as convertibles, boats, bicycles, or motorcycles Touching of the eyebrow area except for when rinsing and applying the post-care

Eyeliner

Expect light to moderate swelling and redness. Teabags or ice packs maybe used to minimize swelling the day of and the day after the procedure. Use Aquaphor ointment or Vaseline around the treated area for 2 to 3 days following the procedure. You must use a new mascara to avoid contamination.

Lip liner/lip color

expect moderate swelling, usually one to two days following the procedure. Applying ice for the first two hours is most important, continue throughout the day. Keep moist with Aquaphor, Vaseline or the ointment provided by your practitioner for the next 5 to 7 days. Then switch to Chapstick we're lipstick with an SPF of 15 or greater, as the sun tends to feed lip color quickly. After the procedure the lips may appear to have too much color. You may add make up to soften the color after 3 to 4 days the color will become lighter as the epidermidis sloughs off it will appear that you have Lost all of the color. However when your lips are healed completely the dermal layer will gradually become darker. Two or three applications may be required to achieve the desired results it is not uncommon to lose up to 70% of the color on the first application.
Extra Tips:

Before showering apply a layer of post-care cream to protect your eyebrows from moisture. During the shower keep your face away from the showerhead.

Itching and flaking may appear during the first seven days post-microblading procedure. However, experience has shown that by following these after-care instructions, these symptoms may quickly disappear.

The healing of deeper wounds might last between 14-21 days. Touch-ups and/or correction of the shape-design is recommended only after this period.

If you have any unexpected problems with the healing of the skin, please contact immediately, to discuss further instructions. can be reached on his/her cell phone:

At the first sign of infection, allergic or adverse reaction, consult with a health care practitioner and report to the Texas Department of State Health Services, Drugs, & Medical Devices Group at 1-888-839-6676

What to expect during and after your microblading session

Your new temporary eyebrow will go through several phases during the healing cycle.

The pigment will appear very sharp and dark immediately after the procedure. This is because the pigment is still sitting on top of your skin, and has not yet settled in completely. The color of the pigment will soften gradually. Do not be alarmed if you see some pigment on the cotton swab, as this is excess pigment and/or body fluid that is naturally exiting your skin.

Once the healing of the skin starts taking place, it will look like dandruff flakes or dry skin. This might give you the impression that the color pigment is fading too quickly, however, this is just superficial color and dry skin being naturally removed from your eyebrows.

Once completely healed, after 2 weeks, always apply a layer of sunscreen SPF 30 up to SPF 50 on your eyebrows when exposed to the sun. Sun exposure might cause the color pigment to fade away more quickly.

You can now enjoy your beautiful new temporary eyebrows. You will simply love your new gorgeous fresh look!
Name*

First NameLast Name
I have read the above information regarding after care information and istructions.*
Date*

MonthDayYear
Date
Please Sign that you have read and received a copy of these after care instructions.*

Clear

This Section is to be filled out by PMU Professional (you can submit your form if you reached this point)
Date:
Pigmaents:
Additional Notes:
File Upload

Cancelof
Needle/lot/Exp
Should be Empty:

General Medical

Photo Release

Patch Test Consent Form

This Section is to be filled out by PMU Professional (you can submit your form if you reached this point)