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.

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.

Signature of Client X

Clear

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

Clear

Signature of Practitioner

Clear

Date