Cosmetic Tattoo/Microblading or Powder Brow Re-Consent Form
This is a legal document. Please read carefully (Jealousy Studios, JMP Ventures LLC)
Client Information
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Existing Client Re-Consent Form
Are you under the influence of drugs or alcohol?
Yes
No
FEMALE ONLY: Pregnancy or Nursing?
Yes
No
Has your health history changed regarding medication, joint replacement, or anything artificial in your body?
Yes
No
Any new allergies since your last appointment?
Yes
No
Other
Any Changes in medication you are currently taking since your last procedure?
Yes
No
Other
Any new cosmetic procedures since your last appointment? (Botox, filler’s, facelift etc.)
Yes
No
Other
Top ups may be required we cannot say if you will need extra sessions top ups . Top ups under 6 month are $100 the first hour & $50 each additional hour, 6-9 month Touchups are $275 per session, and 9-12 month Touchups are $350 and 18 month plus touchups are $400. A $50 deposit is required upon booking. One consultation visit is free of charge. Any additional consultations are subject to fees. 1. A 24 hour notice is required to reschedule a consultation appointment. If you fail to cancel/reschedule this appointment within this time frame, a $50 prepaid deposit is required to schedule another consultation. The $50 deposit will be applied toward any procedure of choice. 2. Please do not bring children to appointment(s)3.After the consultation, a written price quote and a copy of these appointment policies are given. Clients are never pressured to schedule a procedure. In fact, all procedures should be carefully considered before scheduling them.4. To reserve an appointment for a procedure, a deposit of $50 is required. The deposit will be applied toward the cost of the procedure. Pregnant or nursing women or anyone under the age of 18 will not be considered for tattooing. Please advise me now if any of these apply.5. If an appointment must be rescheduled, a 24 hour notice is required in order to fill the opening in the schedule. The deposit will be applied toward the rescheduled appointment. However, if you fail to reschedule and not come at your appointed time, the deposit will not be refunded or reapplied and the full price of the procedure will be due with another procedure time deposit.6.The first visit of the process is the Saturation visit. The following visit is known as the Focus visit. As the names imply, the Saturation visit accomplishes the basic design and color saturation, and the Focus visit addresses perfection by focusing on balance, symmetry and detail of the healed result. There is a $100 hourly charge for any additional Focus visits as long as they are completed within 30 days of the previous visit. 7.A cancellation/rescheduling of a Focus visit is required 24 hours in advance. If you fail to reschedule and not come at your appointed time, the complimentary pre-booked Focus visit of $50 per hour is forfeited and an up Front Deposit of $150 ($50 additional hourly rates apply) per follow up procedure will be required. Please respect our time and our other clients time.8.A Color Assessment appointment should be scheduled at the end of the first year and if a Touch-Up is needed, there is an additional charge per procedure. If, at the first year assessment, the touch-up is determined unnecessary, the charge for the second year touch-up may be more. The length of time one waits in between touch-up visits will determine all fees. 9.All color fades and your cosmetic tattoo will require maintenance. The amount of fading depends on several variables including medications and topical treatments, but is primarily due to sun (ultra-violet) exposure; therefore measures should be taken to protect your permanent cosmetics from the sun. I will not ask for a refund or hold accountable nor responsible any employee of JMP Ventures LLC. If I decide to see a different artistoutside of JMP Ventures LLC for my touchup service or any additional services I will not hold JMP Ventures LLC accountable. The undersigned, received these appointment policies both verbally and in written form and / agree to comply with them.
Acknowledgment and Waiver
*
I allow my tattoo to be photographed and be used for Jealousy Studios portfolio showcased.
*
I understand that the color selection and color results in all procedures are not an exact science.
*
Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliner, lipliner and/or Full lip color
*
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 give my consent to JMP Ventures LLC to confer with my physicians for medical information required for thesafety of my procedures.
*
I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them.
*
I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck withmy needle and take a blood test for their safety & disclose all test results to my practitioner.
*
I am aware that if an infection occurs after I have received Permanent Cosmetics to see with my primary physicianor an emergency room immediately.
*
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 make up dark or even black. I agree to inform my esthetician or anyone operating such that I have permanent make up.
*
I acknowledge that the Jealousy studios does not offer refund or any free service, no exceptions.
*
I absolutely understand and accept that such procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed.
*
I agree that the Jealousy Studios does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo now & in the future. .
*
I agree that the Jealousy Studios does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo now & in the future. .
*
I understand that I need to take care of the microblading by following the instructions given to me by Jealousy also you will revive a paper with instruction on to remind you
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking good care of my tattoo.
*
If you bleed a lot during treatment this can have an effect on healing this is something we cannot control
*
I indemnify and hold harmless Jealousy Studios against any claims, expenses, damages, and liabilities.
*
I confirm that the information I provided in this document is accurate and true.
*
Depending on the procedure(s), which I select, I accept responsibilityu for determining the shape, and position of eyebrows, eyeliner, lipliner and/or Full lip color
*
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.
Client Signature
Client Signed Date
-
Month
-
Day
Year
Date
“Practitioner leave blank” Needle: Name/Lot#/Exp. Date
“Practitioner leave blank” PIgment: Name/Lot#/Exp. Date
“Practitioner leave blank” Anesthesia(primary & secondary) : Name/Lot#/Exp. Date/time on
“Practitioner leave blank” Machine type/level used
“Practitioner leave blank” Tolerance Level: L/M/H
“Practitioner leave blank” Additional Notes
“Practitioner leave blank” Practitioner Name
“Practitioner leave blank” Signed Date
-
Month
-
Day
Year
Date
“Leave Blank”practitioner ID Verification & Signature
Back
Next
Submit
Should be Empty: