Client Information
Please Review and Complete the Following:
Full Name:
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First Name
Last Name
Date of Birth:
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Month
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Day
Year
Date
Age (Must be 18yrs+):
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Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
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Area Code
Phone Number
E-mail:
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example@example.com
Where did you hear about ChevelonBB? If someone referred you, please enter their name:
Employer:
Emergency Contact:
Name
Contact Number
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Client Medical History (Please check all boxes that apply):
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?
Difficulty numbing with dental work
Facial Tumors/ Growth/ Cysts
Tan by booth or salon
Chemotherapy/ Radiation
Accutane or acne treatment
Oily Skin
Autoimmune disorder
Brow/Lash Tinting
Pregnant now – Breastfeeding now
Take medication before dental work
Abnormal Heart Condition
Drink caffeine daily
Take blood thinners
Alcoholism
Facelift
Bleed Easily
Forehead/Brow Lift
Hepatitis A B C D
Diabetes
History of MRSA
I have been vaccinated at least more than 2 weeks ago.
Threads
Botox
Facial Fillers
Vitiligo
Do you have any medical conditions, diseases, or disorders not listed above? If so please type:
Are you taking any medications that may increase bleeding or slow down healing? Please include any blood thinners, immune suppressants, steroids, and fish oils:
Allergic reaction to latex, metals, hair dye, food, or any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc. Please type:
If you have had Cancer, please type in year:
If you have had a Chemical Peel, please type in last treatment date:
If you have had Botox or Threads, please type in last treatment date:
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Eyebrow Permanent Makeup (PMU) Procedure Consent (Please Check ALL Boxes):
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I understand the PMU procedure, is a type of cosmetic tattooing, with the usual healing period of 6-8 weeks, after which the second touch up visit is required and mandatory, in some cases more visits may be needed. The final color and shade result will be achieved 6-8 weeks after my last touch up visit and these may vary with time. It is my RESPONSIBILITY to divulge any and all medical, and or history changes to Chevelon Brow Bar before my touchup session. Signing below gives permission to Chevelon Brow Bar to perform my touch up at or around 6-8 weeks after my initial procedure.
I understand during the healing period redness, swelling, scabbing of the skin, irritation, itching, minor bleeding, rush, and other effects are possible.
Final PMU results can last, on average 6-18 months and may vary depending on the skin type, skin care, and lifestyle. I fully understand that my procedure involves applying pigments into the skin, and it is a type of permanent makeup; I haven’t been given a representation that the results will be removed.
I am aware that the results can be affected during the healing process by: medication, skin type, smoking, drug and alcohol use, use of cosmetic skin care products and makeup on the eyebrow area, activities causing sweating, eyebrow plucking, cosmetic surgery, use of cosmetic injections and many other factors.
I am informed that the use of numbing topical cream can cause some sensitivity, discomfort, allergic reaction, redness, swelling and other reactions, depending on the skin type and sensitivity. I have informed the artist of any known allergies or skin sensitivities.
The following medical conditions require consent from my medical provider: Diabetes, HIV, hepatitis, high blood pressure, thyroid disease, hemophilia, leukemia, anemia and any other blood disorders, any type of skin cancer, pregnancy, nursing, and any type of liver disorders.
I trust and will follow ONLY my artist's recommendations. Shall I choose to ignore my artist's recommendations and seek knowledge on google or social media from third parties or get the same area treated by others after my procedure at Chevelon Brow Bar, I understand that I automatically release my artist and Chevelon Brow Bar from any liability and or responsibility.
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent makeup.
I have read through the before and after care instructions online at https://www.chevelonbb.com and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.
I fully understand THE PERMANENT MAKEUP ARTIST DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as/or substituted for advice from a medical professional.
I acknowledge it is not reasonably possible for the Artists of Chevelon Brow Bar to determine whether I might have an allergic reaction to the pigments or processes used in my procedure, and I agree to accept the risk that such a reaction is possible. I waive the patch test, I release the technician from liability if I develop an allergic reaction to the pigment.
I understand the permanent skin pigmentation procedure carries with it possible complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. I understand this is a tattoo process and therefore not a science but an art. I request this permanent skin pigmentation procedure and accept the permanence of it, as well as the possible complications and consequences of the procedure.
I understand that I will need a touch up session and it is mandatory. Results are not determined until after that touch up session is complete. I understand that if I do not complete the mandatory 6 - 8 week touch up session, the procedure is left unfinished and I will not be eligible for the annual color boost pricing and will start again as a new client session in the future.
I agree to release and forever discharge and hold harmless the Artist, Chevelon Brow Bar, and all employees from any and all claims, damages or legal actions arising from or connected in any way with my permanent makeup , or the procedure and conduct used in my permanent makeup.
I give consent to be contacted via SMS text messages by Chevelon Brow Bar during business hours regarding but not limited to: important after care information, special deals, and promotions.
I understand the taking of before and after photographs and/or videos of my permanent makeup procedure are required. I give my consent and release to Chevelon Brow Bar to use any photo and/or video of myself for marketing, insurance, and future touch-up purposes.
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about obtaining a permanent makeup treatment, and that all of my questions have been answered to my full satisfaction.
Please upload a current photo of your brows without makeup on them. Be sure to use natural lighting; this is best in front of a window or outside
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Permanent Makeup Aftercare Form (Please Check ALL Boxes):
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I understand that lifestyle, medications, smoking, metabolism, facial surgery, other procedures, and age of skin can all contribute to fading. Though rare, infection is also possible.
I will avoid sweating such as from vigorous exercise for at least one week post-procedure. Sweating can cause the microblading strokes to expand and blow out.
I will avoid exposing the area to excessive moisture or humidity, such as: facials, swimming, whirlpools (hot tubs), saunas, chlorine spas and pools, steam rooms, and steamy showers.
I will avoid tanning beds, sun, yard work, harsh soap, peroxide, Neosporin and chemicals (including skin cleansers, makeup removers, alpha hydroxyl creams, and even tooth whitening toothpaste), near the treated area until healed.
I will avoid Retin-A, moisturizers, glycolic acids, exfoliants and anti-aging products at all times (not just during healing) on all micro pigmented areas. These can cause pigments to fade and lighten prematurely.
If I see signs of infection such as persistent increased redness or swelling, fever, drainage, or oozing, I will contact my medical doctor immediately.
I understand temporary side effects from micropigmentation include but are not limited to: redness, swelling, puffiness, bruising, dry patches and tenderness. I may apply ice packs as necessary to prevent or reduce swelling, but will Not get the area wet.
I understand that immediately after the microblading procedure, for the first two hours, I should gently blot the area with a clean gauze pad, paper towel or tissue periodically to absorb any excess blood or lymph fluid.
I understand that 2 hours after the procedure, I will wash area lightly with mild soap with clean hands and again before bed. Pat dry around the eyebrows and allow them to air dry (at least an hour, they should feel slightly tight) and then apply a very thin coat, the size of a grain of rice, of aftercare ointment (provided to me by my artist) to the area as advised. I will continue this process once daily at bedtime for the next 7 days.
I understand that days 1-5 The eyebrows are approximately 20- 25% bolder and darker in width than they will be when healed. Light to moderate swelling and redness can cause the color of the pigment to appear darker.
I understand that natural exfoliation occurs around days 6-10 and can cause the excess pigment surrounding the eyebrow to flake away and a more narrow appearance will result. I will NOT pick any flakes or scabs. Color and skin will finish the natural exfoliation process and will appear softer and grayer for a few days until color clarifies.
I understand that on days 8-14 I will do NOTHING to the brows. No picking, touching, pulling or plucking, this can cause undesirable results and or scarring. I will leave scabs alone! The longer the scabs remain intact, the better pigment retention I will have.
I understand that on days 8-10 new skin will heal over the pigmented area and result in a softer appearance of my eyebrows. It will seem as though my big bold eyebrows are now gone. The color has lightened from its initial overly-dark appearance.
I understand that days 11-24 the final color begins to stabilize and show through my fresh skin. The color will continue to soften and even out as the healing process completes.
I understand that I should not wear makeup on my eyebrows for at least 14 days.
I understand that pigments will slowly fade overtime according to my specific metabolism, skin type, sun exposure, medication, facial surgery, and smoking. I will be sure to schedule maintenance visits, if desired, to keep the eyebrows looking fresh.
I UNDERSTAND AND ACCEPT THAT FAILURE TO FOLLOW THE POST-PROCEDURE INSTRUCTIONS ABOVE MAY RESULT IN A LOSS OR DISCOLORATION OF PIGMENT RESULTING IN A NEED FOR MORE FREQUENT TOUCHUPS.
By my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.
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