PMU_Re-ConsentFormForTouchUpVisits

Re-Consent Form For Touch Up Visits

I absolutely understand and accept that the touch up procedure is a process, often requiring multiple applications of color to achieve desirable results and that 100% success cannot be guaranteed.

PLEASE READ AND INITIAL ALL OF THE FOLLOWING BOXES... (please be advised that we absolutely can not treat you if you are pregnant or nursing, under the age of 18 without parent consent, have had any kind of organ transplant or lupus.

Name *

First Name Last Name

1. I absolutely understand and accept that the touch up procedure is a process, often requiring multiple applications of color to achieve desirable results and that 100% success cannot be guaranteed.

I have received, reviewed, and understand the pre & post-procedural instructions as given to me and agree to follow them.

2. I have received, reviewed, and understand the pre & post procedural instructions as given to me and agree to follow them.

Depending on the procedure(s) which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lip liner and/or full lip color.

3. Depending on the procedure(s) which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lip liner and/or full lip color.

I understand that the color selection and color results in all procedures are not an exact science.

4. I understand that the color selection and color results in all procedures are not an exact science.

5. I waive all responsibility to my practitioner, BROWHAUS STUDIO, Andrea Cerini, LLC, and I assume full responsibility that I can see to drive, perfectly.

Iunderstand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restalyne and I assume this responsibility.

6. I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restalyne and I assume this responsibility.

I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics (tattoo When asked if you have a tattoo, you say yes.

7. I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics (tattoo). When asked if you have a tattoo, you say yes.

8. If I am a contact lens wearer, I realize that I must keep my contact lenses out the day of an eyeliner procedure.

9. I understand that this procedure will fade and this fading can alter the original pigment color and that this simply determines that it is a time for a touch up visit.

10. I realize this is an elective cosmetic procedure, not an exact science, and is not medically

10. I realize this is an elective cosmetic procedure, not an exact science, and is not medically necessary.

11. It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment.

12. I understand that many lasers & IPL's (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines; may or will turn permanent makeup dark or even black. I agree to inform my esthetician or anyone operating such devices that I have permanent make

12. I understand that many lasers & IPL's (Intense Pulse Lights) including those used for hair removal, anti aging, Photo Facials, removal of lines; may or will turn permanent makeup dark or even black. I agree to inform my esthetician or anyone operating such devices that I have permanent make up.

13. I give my consent to BROWHAUS STUDIO, Andrea Cerini, LLC, to confer with my physicians for medical information required for the safety of my procedures.

14. I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner.

15. I am aware that if an infection occurs, after I have received Permanent Cosmetics, I am to see my primary physician or an emergency room physician, immediately.

16. If I had permanent cosmetics performed previously by another practitioner, I do not hold my practitioner BROWHAUS STUDIO, Andrea Cerini, LLCresponsible for future allergic reactions or contraindications.

17. Are you Pregnant? Yes []No []

Yes

] No

18. Is your Health History the same as your last visit? Yes []No [

Yes

No

If not, please specify any new medications and why they were prescribed to you.

ACCEPTANCE: I have read and understand these risks listed above and they have been explained to me. I DID NOT JUST SIMPLY SIGN THIS DOCUMENT WITHOUT READING IT. I certify that the information in the above questionnaire is accurate and my questions have been answered. I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be performed at my request. Touch Up pricing honored for 3 months after procedure. Thereafter, touch up price is subject to increase.

Name *

First Name Last Name

Signature of Client X *

Clear

Name

First Name Last Name

If client is under the age of 18, signature of Guardian X

Clear

Signature of Practitioner

Clear

Date *

Date