Ombré Brows Consent Form
Please be advised that I am obligated to perform procedures in strict compliance with all hygiene and health protection measures. The information you will provide is confidential and it shall also be handled in that way.
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example@example.com
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Health Questionnaire
Please understand that eyebrow semi permanent makeup is not for everyone. In order to find out if you are fit for this procedure, please answer the following health questions truthfully. Coccolare Beauty Spa and its practitioners will assume no liability in the event you give false information to obtain the treatment.
Do you have any of the following conditions or are you taking any of these medications?
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Hemophilia
Hepatitis
HIV-AIDS
Diabetes
Skin diseases
Eczema
Allergies
Autoimmune diseases
Herpes
High blood pressure
Thyroid disease
Leukemia
Anemia
Glaucoma
Blood disorder
Liver disorder
Infectious diseases / high fever
Epilepsy
Cardiovascular problems
Blood thinning medication
Pregnant or nursing
Wound slow healing
Prone to keloid scarring
Surgery in the last 14 days
I was exposed to radiation in the last 14 days
I had a medical intervention recently
NONE OF THE ABOVE
Other
If you checked any of the boxes, please explain more here:
I certify that my given answers are true:
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Signature
Contractual Obligation
Please carefully read over each bullet point and provide your consent
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Semi permanent Makeup is an art and not a science. Client’s result will vary and using a makeup pencil or brow powder may still be needed.
Semi permanent makeup always leads to skin injury. Therefore, it is important to carefully and gently nurture your skin after the treatment to allow healing without complications. Inadequate care in healing phase of the skin can lead to poor results and Coccolare Beauty Spa and its practitioners cannot be held liable for it.
A touch up may be necessary within 6-8 weeks after your eyebrows have healed. If most of the color has faded then this will not be considered a touch up and all fees for a new service may apply. Touch ups are to be performed within 6-8 weeks. If you fail to come in for a touch up during that time frame, you will charged as a fee. For oily skin it may be necessary to perform more corrections.
I am aware that the results can be affected by: medication, skin type, smoking, drug and alcohol use, use of cosmetic skin care products and makeup on the eyebrow area, activities causing sweating, eyebrow plucking, cosmetic surgery, use of cosmetic injections and many other factors.
The minimum or maximum duration of Ombre Powder Brows cannot be determined with certainty, nor can the warranty be given on performed treatment.
I am informed the pigments after initial procedure may partially and/or fully fade and/or disappear and full success cannot be guaranteed and the second touch up visit may be needed.
In the first seven days eyebrows are up to 40% darker and 10-15% thicker.
Depending on the skin structure after the first treatment small scabs with a loss of drawn hairs may occur and color intensity may change.
I am informed about and agree with the following: The permanent makeup procedure, is a type of cosmetic tattoing, with the usual healing period of 4-6 weeks, after which the second visit is usually required, in some cases more visits maybe needed. During the healing period redness, swelling, scabbing of the skin, irritation, itching, minor bleeding and other effects are possible.
I understand that the FDA does not approve any pigments used for this procedure, and that the health effects of use are unknown.
I agree to release and forever discharge and hold harmless the Artist and all employees of Coccolare Beauty Spa from any and all claims, damages or legal actions arising from or connected in any way with my permanent makeup , or the procedure and conduct used in my permanent makeup .
I fully understand THE PERMANENT MAKEUP ARTIST DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as/or substituted for advice from a medical professional.
I acknowledge I am over the age of eighteen and that I have truthfully represented to my artist that the obtaining of a permanent makeup is by my choice alone. I consent to the application of the permanent makeup and to any actions or conduct of the representatives and employees of Coccolare Beauty Spa reasonably necessary to perform the procedure.
I acknowledge that a permanent makeup is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my permanent makeup . To my knowledge, I do not have any physical, mental or medical impairment or disability, which might affect my well being as a direct or indirect result of my decision to have this procedure
I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent makeup .
I realize that variations in color and design may exist as ultimately applied to my skin. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.
I acknowledge that infection is always possible as a result of the obtaining of a permanent makeup, particularly in the event that I do not take proper care of my permanent makeup. I have received aftercare instructions and I agree to follow them while my permanent makeup is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.
I acknowledge it is not reasonably possible for the representatives and employees of this permanent makeup salon to determine whether I might have an allergic reaction to the pigments or processes used in my procedure, and I agree to accept the risk that such a reaction is possible.
I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the procedure area that may interfere with said procedure
If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition or take medicine, which thins the blood, I have advised my artist. I am not pregnant or nursing. I am not under the influence of alcohol or drugs.
The final result will be achieved 6-8 weeks after the last visit and may need a touch-up.
I am informed that in case numbing topical cream is to be used, some sensitivity, discomfort, allergic reaction, redness, swelling and other reactions are possible, depending on the skin type and sensitivity.
The following medical conditions require consent from the doctor: Diabetes, HIV, hepatitis, high blood pressure, thyroid disease, hemophilia, leukemia, anemia and any other blood disorders, any type of skin cancer, pregnancy, nursing any type of liver disorders. I guarantee that I read over the health questionnaire and answered as truthfully and to the best of my ability as possible
I approve of the shape and design created by my permanent makeup practitioner and I give my consent to use a tattoo machine to apply pigments into my skin in the eyebrow area and modify the look of my existing eyebrows.
I acknowledge that the correcting and the revision of any type of permanent makeup, tattoo or microblading, previously performed by other providers involves additional risks due to unknown factors, such as but not limited to, brand, color, time, skin reaction, depth and others and the practitioner has no full control over the potential results and I accept full responsibility for the final outcome and complications.
In case I will need an MRI scan I will notify and discuss my permanent makeup procedure with my health provider/doctor.
I hereby grant my permanent makeup practitioner the irrevocable, perpetual, exclusive right and permission to use photographs/video of me for all media throughout the world including print, internet, other electronic medium; alone or combined or incorporated with other materials; images of me before, during, immediately after the treatment, before and after the touch up and after healing; and I agree that my practitioner owns the property rights for such images, digital files and materials.
I acknowledge and give my permission that such images and digital files maybe made public on the Internet and I might be identified.
I release and waive any current and future claims, demands, actions, causes of actions, suits, costs, liabilities, damages against Coccolare Beauty Spa, my practitioner, its employees, owners, directors, officers and trustees for the right of privacy and publicity violation and invasion, intrusion of solitude and seclusion, public disclosure of private facts, health record protection violations, false light, appropriation of the name or likeness, tort of defamation, commercial exploitation and other privacy related rights violations.I waive my right to approve the changes and final result and give my consent to the editing, retouching and modifying.
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a permanent make up treatment and that all of my questions have been answered to my full satisfaction.
I saw that the needle that’s going to be used for my treatment is new and closed and not expired.
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