Client Consent & Consultation Form

Client Consent & Consultation Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Phone Number*
(000) 000-0000
Date*
MM/DD/YYYY
Emergency Contact First Name* Last Name*
Emergency Contact Phone Number*
Technician Name *
Welcome to Lane Beauty Bar LLC, thank you for booking with me! I can't wait to make your beauty goals a reality! Please be aware some services should not be performed under certain medical condition. It is your responsibility to inform the body art technician of any pre-existing conditions, limitations or specific sensitivities and to inform your body art technician if you feel any discomfort during the session. You understand and voluntarily accept any risk associated with any given body art service or use of any of the company’s facilities, and hereby release Lane Beauty Bar LLC and any of its employees from all liability for any injury, including & without limitation to: personal, bodily or mental injury, economic loss or any damage to you resulting there from any such injury or damage resulting from your failure to disclose any pre-existing condition, limitation or specific sensitivities, or your failure to inform your body art technician of any discomfort during the session. Your body art technician may determine that it is unsafe for you to proceed with or continue a session due to health related concerns. In this event you may be required to provide a physician's medical release prior to continuing treatment.
I hereby consent to and authorize the technician/esthetician to perform permanent makeup procedures*

Yes, I authorize all procedures from any employee at Lane Beauty Bar LLC
*Please note that at Lane Beauty Bar LLC we do NOT accept minors for any body art procedure and you will be required to show ID prior to your appointmet
Please indicate which procedure you would like below*
Health Questionnaire Please Check All That Apply*

Diabetes or other conditions which may affect blood circulation and/or ability to fight infectionHistory of hemophilia or excessive bleedingHistory of skin disease, skin lesions, or skin sensitivities to soaps or disinfectantsHistory of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals, or other sensitivities related to body art proceduresHistory of epilepsy, seizures, fainting or narcolepsyTreatment with anticoagulants or other medications that thin the blood and/or interfere with blood clottingCurrent pregnancy and/or breastfeedingAre you taking AccutaneAre you using any topical medicationsAre you using any other skin thinning products or drugsAre you using RetinoidsHave you ever had an adverse reaction to any previous treatmentsDo you have and blood borne communicable illnesses such as, Herpes Simplex Virus (HSV), Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), or Acquired Immunodeficiency Syndrome (AIDS)Do you spend excess amounts of time in the sun or tanningDo you have cancer or have you ever been treated for cancerNone of the above
Are you using any exfoliating acids? If so which ones:*
Any recent surgery if so, what? *
Please upload a photo of the procedure area with no makeup *

Cancelof
For eyebrows please upload a photo of how you normally wear makeup on them

Cancelof
What are your concerns with the procedure area? *
Example: Scarring, Shape, Color
What are you hoping for out of your procedure?*
Example: Filling certain areas, Color correction, Larger or smaller shape
Have you had previous permanent cosmetic procedures?*

yesNo
What other permanent cosmetic procedures have you had?*
What face creams & face washes do you use?*
What would you say your skin type is?*

OilyDryCombination
I acknowladge that I may require additional treatments/procedures to obtain the expected results at an additional cost.

I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.
Signature*

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AFTERCARE
- Gently blot the area with a clean damp towel to absorb any excess lymph fluid every 30-45 Minutes the day of your procedure until any oozing has stopped (removing this fluid prevents the hardening of lymphatic fluids that cause scabbing)
- Wash 2x daily with a mild scent free soap to remove bacteria
  Gently pat dry with a clean tissue
- Do not use any cleansing products containing: glycolic, lactic, or AHA acids, or any kind of exfoliants (chemical or mechanical scrubs)
- Apply a pea sized amount of after care cream (do not over saturate your brows) reply 3 times a day. If you have extremely dry skin or notice the cream is completely dried up feel free to apply more as needed.
IMPORTANT REMINDERS
- Use a clean pillowcase
- Wash hands before touching the procedure area
- Do not pick at or exfoliate scabs, let them fall off naturally
- No facials, botox, chemical treatments, or microdermabrasion for 4 weeks
- Avoid excessive sweating for 1.5 weeks
- Avoid direct sunlight or tanning for 4 weeks
- Avoid long hot showers or excessive exposure to water for the first 10 days
- Avoid sleeping on your face
- Keep your face out of bodies of water such as: pools, tubs, lakes etc. These hold bacteria which we would like to keep away from your tattoo so it can heal properly.
- Avoid makeup on or around your procedure area
- The healing process can take 3-4 weeks remember everyone heals differently, give your body time to heal and DON'T PICK
SIGNS OF INFECTION INCLUDE BUT ARE NOT LIMITED TO
- Fever
- Rash
- Blisters
- Sores that may have crusting
- Chills
- Sweating
- Vomiting
- Weakness
- Drowsiness
- Worsening pain
- Continued redness or discoloration
*If you notice one or more of these symptoms please contact a certified health care provider.*

I have read and understand aftercare instructions, reminders, and signs of infection
Requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.*

I voluntarily agree to undergo this treatment/procedureAlthough it is impossible to list every potential risk and complication, I have been informed of possible complicationsI understand that it is imperative to my health and safety that I disclose all of the informationI understand that no specific guarantees of the results can or have been madeI have read and understand all pre-treatment, post-treatment, and home care instructions.
Advertising, and Promotional Purposes.

Yes, I consent to “before-and-after” photographs for the purpose of documentation and promotional purposesNo, I do NOT consent to “before-and-after” photographs for the purpose of documentation and promotional purposes
I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold them harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, who was stated previously, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.*

Yes, I Understand
Disclosure Statement and Notice for Filing Complaints

Public Act 375, which was enacted in December of 2010, indicates that individuals shall not tattoo, brand, or perform body piercing on another individual unless the tattooing, branding, or body piercing occurs at a body art facility licensed by the Michigan Department of Health and Human Services. Body art facilities are required to be in compliance with the “Requirements for Body Art Facilities,” which provide guidelines for safe and sanitary body art administration. As with any invasive procedure, body art may involve possible health risks. These risks may include, but are not limited to: transmissions of bloodborne diseases such as HIV and viral hepatitis, skin disorders, skin infections, and allergic reactions. In addition, persons with certain conditions including, but not limited to, diabetes, hemophilia or epilepsy, are at a higher risk for complications and should consult a physician before undergoing a body art procedure. If you wish to file a complaint against a body art facility related to compliance with PA 375 or have concerns about potential health risks, please visit www.michigan.gov/bodyart.
The answers provided by me were true and correct. If I reported one or more of the above conditions, I am advised to consult a physician before undergoing a body art procedure. I acknowledge that I have:*

I have read a copy of the Disclosure Statement and Notice for Filing Complaints.I have received a copy of the Aftercare Information Sheet.I have completed the Client Health Questionnaire, and received any additional, applicable information.I understand that no specific guarantees of the results can or have been madeI have read and understand all pre-treatment, post-treatment, and home care instructions
I understand that there is a 50% non refundable deposit required for all permanent makeup procedures. We at Lane Beauty Bar understand that things do happen. Please reach out as soon as possible for any changes. A 24hr notice is required for appointment changes. Appointment changes cannot be made more than once for the same appointment (moving appointment dates and times)*

Yes, I understand
Client Name (Printed)*
Signature*

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