Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
Please list the name of the Brow Artist providing PMU:
*
Have you ever had a brow tattoo? (Micro-blading or Ombré)
*
Yes
No
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-A, Renova, or Accutane within the past 6 months? If so, when was the last time?
*
Are you using any other skin thinning products and/or drugs that thin the blood?
*
Yes
No
Do you use tanning beds and/or are exposed to the sun on a regular basis?
*
Yes
No
Have you had alcohol within the last 24 hours?
*
Yes
No
Are you currently taking any medications? If so, please list.
Have you been treated for cancer? If yes, when and what types of therapies were used?
Please list any illness/conditions which you are currently being treated for by a medical professional.
Do you have any open skin lesions on the face?
*
Yes
No
Do you have any allergies? If so, please list.
Are you currently pregnant and/or breast feeding?
*
Yes
No
Do you donate blood? If so, you CANNOT donate blood for the next 12 months.
*
Yes
No
Please read this section thoroughly and check the box to agree to the terms:
*
I give permission to Selfie By SK to perform the procedure we have discussed and will hold her harmless from any liability that may result from this treatment.
I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for time specified in brow aftercare.
I hereby authorize Selfie by SK to perform permanent cosmetic enhancement on myself. If any unforeseen condition arises in the course of the procedure(s), I further request and authorize her to use her full judgment and do whatever she deems advisable and necessary in the circumstances.
I am not under the influence of alcohol or drugs or any other substances, legal, or otherwise.
I understand the final result depends on how I follow the aftercare, skin type, lifestyle and coming for touch-ups.
I understand there is a no refund policy and no guarantee has been made as a result of this procedure.
I consent to have photos/videos of the procedure taken and possibly posted online.
I understand some permanent makeup pigment can only be removed with a laser or saline.
I understand that Selfie By SK does not offer removal services.
I am at least 18 years old. I am not under the influence of drugs or alcohol.
I have not had Botox/Dysport or any fillers in the procedure area in the last two weeks.
I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if an allergic response occurs.
I am aware that a sensitivity reaction to numbing creams and gels can occur and accept all responsibility if allergic response occurs.
I understand that dyes, inks and pigments are not approved by the Food and Drug Administration(FDA) and the health effects are not known.
I accept that the highest standards of hygiene are met and that sterile disposable needles are used for each individual client, procedure, and visit.
I understand that the touchup procedure, if required, will be performed 6-8 weeks after the initial procedure.
I understand that permanent makeup can have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I understand that immediately after the procedure the enhancement can be 40% to 60% darker than the desired result and can take between 7-14 days to lighten. I understand that the true color will be visible 1 month after each application, and that the color may vary according to skin type, age, medication and skin conditions. I accept that some skins accept color more readily than others and no guarantee of an exact effect or color can be given.
I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these concerns with Selfie By SK
By checking this box, I understand that I am opting for an elective semi permanent ombré powder brow treatment/procedure that is not urgent and not medically necessary.
Date:
Signature of Client
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