Consent Form

Name

First NameLast Name

Birthdate

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ARE YOU UNDER THE CARE OF A PHYSICIAN?

IF YES, WHY?

PHYSICIAN'S NAME:

DO YOU TAKE ANY ANTIBIOTICS WHEN GOING TO THE DENTIST?

IF YES, WHY?

DO YOU SUFFER FROM ANY OF THE FOLLOWING:

ARE YOU ON BLOOD THINNERS?

ARE YOU TAKING ANY OTHER MEDICATIONS?

IF YES,WHAT?

ARE YOU PREGNANT OR NURSING?

DO YOU WEAR CONTACT LENSES?

HAVE YOU HAD ANY PREVIOUS EYEBROW TATTOOS DONE BY ANOTHER ARTIST? IF YES, THIS IS CONSIDERED A CORRECTION BROW WITH A SLIGHT EXTRA CHARGE

PROCEDURE TO BE PREFORMED:

I specifically acknowledge that I have been advised of the matters set forth below and agree as follows

I acknowledge that obtaining permanent makeup is my choice alone. The application of permanent makeup will result in a permanent change of my appearance and that needles and/or ink will go into my skin. No representations have been made to me as to the ability to later restore the skin involved in permanent makeup to the original condition, and it is very costly to remove.

I am not pregnant or nursing. I do not have any history of herpes infection at the proposed procedure site. I do not have epilepsy, diabetes, allergic reactions to latex or antibiotics, hemophilia or other bleeding disorders. I do not have cardiac valve disease or suffer from any heart condition or take medication that thins my blood. If I suffer from hepatitis or other risk factors for bloodborne pathogen exposure or any other communicable disease, I have informed the technician of the fact and have been advised of any medications and procedure necessary to promote the satisfactory healing of my tattoo/wound.

I do not suffer from any medical or skin conditions such as but not limited to; keloid or hypertrophic scarring, psoriasis at the site of the permanent makeup/removal, or any open wounds or lesions at the site of the tattoo. I do not have a history of medication use or currently using medication including being prescribed antibiotics prior to dental or surgical procedures.

I have advised the technician of any allergies to latex gloves, soaps or medications. I acknowledge it is not reasonably possible for the technician to determine whether I might have an allergic reaction to the permanent makeup or removal process and further acknowledge that such reaction is possible.

I have truthfully represented to the technician that I am 18 years of age or older. I am not under the influence of any drugs or alcohol. To my knowledge I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a tattoo or removal at this time.

I acknowledge infection is always possible as a result of permanent makeup application or removal, and I agree to follow all suggested instructions concerning the care of the permanent makeup site while it is healing.

I understand I will have permanent makeup or removal using appropriate instruments and sterilization techniques. I understand that the permanent makeup site usually takes 4 weeks or longer to heal. I agree to release and forever discharge, and hold harmless, the technician (Denise), all employees, contractors and the management of the permanent makeup studio from any and all claims of negligence, damages or legal actions arising from or connected in anyway with my tattoo, the procedure, and conduct used in my tattoo and assume all responsibility or the decisions made consenting to this permanent procedure. *

I am aware that permanent cosmetic inks, dyes and pigments have not been approved by the FDA and that the health consequences of using these products are unknown.

I acknowledge and give consent to this permanent makeup studio to use images of my tattoos for marketing. I consent to allowing photos and videos taken of me before, during and after the procedure.

I acknowledge that my semi permanent tattoo can (but isn't likely to) fade, fan, spread and/or migrate.

I acknowledge that the results of my permanent makeup or removal service varies on several factors such as skin type, skin care, sun exposure etc and that is my full responsibility to follow the aftercare instructions provided in order to achieve the best results.

I acknowledge that the technician has the right to refuse service to any client who she deems unfit for the procedure.

I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have about obtaining permanent makeup from Denise and that all of my questions have been answered to my full and total satisfaction.

I understand that this could be a two step process and I might need a touch up after 4-6 weeks to achieve desired color/darkness. I understand that my eyebrows will heal up to 60% lighter because this is a semi permanent tattoo. The touch up is a separate fee ($100) and I am required to place a deposit to book this appointment. I also understand that results very based on skin type and health condition.

I understand that **ALL SERVICES AND DEPOSITS/BOOKING FEES ARE NON REFUNDABLE**

UPLOAD A PHOTO OF YOUR ID, PASSPORT, OR BIRTH CERTIFICATE

SIGNATURE

The Parties covenant and agree that in no event, and at no time during the Term or at any time thereafter, shall either of them disparage, denigrate, slander, libel or otherwise defame the other or the other’s businesses, services, properties or assets, or employees, personnel, agents, or representatives.

DEPOSIT MUST BE PAID WHEN BOOKING APPOINTMENT. YOU MUST BRING CASH TO PAY FULL BALANCE AT THE TIME OF YOUR APPOINTMENT.

INKED UP BROWS

HEALTH HISTORY

CLIENT HISTORY

CONSENT FORM