ESMIA BEAUTY & ACADEMY
Client Consent & Waiver Form
♡ CLIENT INFORMATION
Name
*
First
Last
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
♡ UPLOAD A PHOTO OF YOUR NATURAL BROWS WITHOUT MAKEUP OR FILTERS:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
♡ NEWSLETTER
Would you like to recieve future emails regarding Newsletters, Giveaways, and Promotions?
*
Yes
No
♡ DISQUALIFICATIONS
Statements & Acknowledgments
You MAY NOT book if:
*
You are under 18 years of age.
You have serious medical conditions such as Heart Disorders, Diabetes, Uncontrolled High Blood Pressure, Seizures, Cancer (Or undergoing chemotherapy or radiation therapy), Hepatitis, HIV/Aids, or Anemia.
You have Eczema, Psoriasis, Rashes, or Sunburn on or around your brow area.
Have recieved Botox or Fillers on or around the brow or lip area less than 1 month ago.
You are allergic to pigment, makeup, or numbing agents (Lidocane and Epinephrine)
You are currently on prescription Accutane.
You have received a Covid-19 vaccine within the last 2 weeks.
You are currently sick or experiencing any illness or Covid-19 symptoms.
♡ THE PROCESS AND WHAT TO EXPECT ON YOUR APPOINTMENT
01. Prior to starting the procedure, your PMU Artist will conduct a thorough consultation by asking you specific questions regarding your natural brows, your lifestyle, skin type, goals, and needs. Based on these specifics, we’ll be able to determine the perfect shape and pigment colour best suited for you.
02. During the mapping process, your PMU Artist will use a ruler, mapping string, and brow pencil to plan/map out your brow shape. This will also be the time for you to provide verbal consent of approval to move forward with the shading process. Your brows may look dark during the mapping process, but it will not stay dark.
03. This is the part where the PMU pen implants tiny pigments into the epidermis layer of the skin called shading. The shading process consist of a few passes over the epidermis layer of the skin until the desired result is achieved. After the first pass, a numbing cream is used for additional comfort. Don’t worry, all clients have reported the pain to be very minimal.
♡ PRE-TREATMENT QUESTIONNAIRE
FEMALE ONLY: Are you currently pregnant or breastfeeding?
*
Yes
No
Are you under the influence of drugs or alcohol in the last 24 hours?
*
Yes
No
Have you gotten a Brow Lamination done in the past 2 weeks?
*
Yes
No
Have you gotten brow or lip Botox/Fillers in the past 4 weeks?
*
Yes
No
Have you used Accutane in the past 12 months?
*
Yes
No
Have you used any Retinol/Tretinoin in the past 4 weeks?
*
Yes
No
Do you have any allergies? (Example: Dyes, Pigments, Topical anesthethic, Latex etc.)
*
Yes
No
Other
Do you have any communicable diseases? (Example: HIV, Hepatitis etc.)
*
Yes
No
Other
Do you have any serious skin conditions?
*
Yes
No
Skin conditions (Example: Rashes, Eczema, Infections, Psoriasis, etc.) N/A if none.
If yes, please identify the condition.
List any medical history you have (Example: Diabetes, Cardiovascular Disease, Epilepsy, Anemia, Cold Sore History, or Blood-related diseases/disorders etc.) N/A if none.
If yes, please identify the condition.
List any medications you are taking in the past 6 months. (Example: Blood thinners, Cardiac medications, etc.) N/A if none.
If yes, please identify the condition.
Have you had any major surgeries in the last 6 months? N/A if none.
If yes, please identify the condition.
♡ INFO STATEMENTS | ACKNOWLEDGMENTS | WAIVER
*
I understand that a $100 non-refundable deposit is required to secure my appointment date, and that the remaining balance is to be paid on the day of the appointment immediately after the treatment has been completed. I agree to e-transfer my deposit and all remaining balance(s) to: ESMIASTUDIO@OUTLOOK.COM
*
I understand that the studio does not offer refunds due to the nature of the services. No exceptions.
*
I understand that if I am LATE more than 15 minutes to my service appointment that I will be charged the studio's $25 late fee in addition to the total service charge. I also understand that if I am LATE to my training class that I will not hold liable the studio of all/any of the portion that I’ve missed, however, the trainer will do their best to catch me up.
*
I understand that if I NO SHOW for services or training, the studio will charge my on-file credit card 100% of the original charge. If there is no on-file credit card, the studio will email me an invoice to be paid in full prior to or by its' due date.
*
I allow the PMU Artist [Shenna W.], Esmia Studio, and Affiliates to take/post photos and videos to be used for the purpose of the artist and studio’s advertising, marketing, and portfolio building. I also give consent for my verbal and written testimonials/reviews to be used for the purpose of the artist and studio’s advertising, marketing, and portfolio bulding. I release all rights to the PMU Artist [Shenna W.], Esmia Studio, and Affiliates.
*
I understand that Model Call Sessions will require me to provide a MANDATORY positive review as an exchange for the discounted PMU service.
*
I understand that this procedure is a permanent change to my skin and body.
*
I understand that the pigment may fade quicker and last less than 3 years as it can depend of my skin type, lifestyle, and aftercare.
*
I understand that on some occasions the pigment may not stick if my skin is too sweaty, oily, exposed to heat, and if the advised precare & aftercare instructions are not followed thoroughly by me.
*
I understand that the permanent makeup procedure can be uncomfortable and cause some swelling and redness immediately and up to 7 days after the procedure.
*
I agree that the PMU Artist [Shenna W.] of Esmia Studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo. I understand that there may be immediate or delayed allergic reaction to the pigment or topical anesthetic used, however, allergic reactions are extremely rare. A negative allergy patch test result done on the day of procedure will not guarantee that I will not have an immediate or delayed allergic reaction.
*
I understand that some bleeding may occur during the treatment, and that I may experience increased bleeding if I drink coffee, tea, or alcohol within 24 hours of the treatment.
*
I understand that the pigment can be up to 50% darker initially than the desired results and the pigments will then fade up to 40% lighter within 4-8 weeks post-treatment. And the results and longevity of my PMU is depending on my skin type and how well I followed the precare and aftercare instructions advised to me.
*
I understand that I need to take care of the tattoo by following the aftercare instructions advised to me by the studio. And that I might not get the desired results or get an infection if the advised pre-care and/or after-care instructions are not followed thoroughly.
*
I understand that permanent makeup is a form of tattooing and that a separate touchup treatment (post 4-8 weeks) may be needed in order to complete the process.
*
If you have had a recent MRI scan within 3 months or are scheduled for an MRI scan within 3 months, please discuss the permanent makeup procedure with your physician.
*
I indemnify and hold harmless the PMU Artist [Shenna W.], the studios [Esmia Studio & Lashed Up Artistry Co], and its affiliates against any claims, expenses, damages, and liabilities.
*
Any form of verbal or physical aggression, harassment, bullying, vandalism, or misconduct will not be tolerated at any point before, during, or after the appointment. I understand that I should always be kind and respectful. I agree that the PMU Artist [Shenna W.] and the studio [Esmia Studio and affiliates] has the right to refuse services to anyone at any point. Further, I understand that if I behave and conduct myself as such, my deposit will not be refunded.
*
I confirm that the information I provided in this document is accurate and true.
*
All the above information is not intended to alarm you, however, it is imperative that you are informed of the risks involved.
Signed Date
*
-
Month
-
Day
Year
Date
Client Signature
*
Submit Form
Submit Form
Should be Empty: