Client Intake

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

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

Email*

example@example.com

How did you hear about us? blanks

The nature and method of the proposed permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness, or other discoloration and/or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for but may occasionally occur. Tattoo(s) should be considered permanent; it can only be removed with a surgical procedure and any effective removal may leave permanent scarring and disfigurement.
By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:

(Please initial the line next to the number after you clearly understand each statement)

1 - Are you over the age of 18? blanks*
2 - Are you pregnant or nursing? blanks*
3 - Are you currently taking any blood thinner medication? blanks*
4 - Have you taken Accutane in the past 6 months? blanks*
5 - Do you have any known blood borne illnesses, such as Hepatitis? blanks*
6 - Have you had any alcohol in the past 24 hours? blanks*

Please initial the following questions unless asked to type "Yes" or "No"

1. I have informed the practitioner of any and all of my known allergies. I acknowledge that is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, to latex, iodine, or other products routinely used in a body part procedure; dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible. *

1a. I have informed the practitioner of any medical condition that may affect my ability to be a candidate for micropigmentation including hepatitis, diabetes, and/or jaundice in the last 12 months. *

1 b. I have informed the practitioner if I have ingested blood thinners such as aspirin or ibuprofen, alcohol or other intoxicants, or if I have a condition that may affect the procedure or healing process such as lupus, diabetes, or hemophilia within 24 hours prior to receiving a body art procedure.*

2. I acknowledge that complications as a result of permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications. *

3. I realize that my body is unique and neither Brows By Sierrah nor its employees or contractors can predict how my skin may react as a result of the procedure. *

4. I have previously had micropigmentation performed by someone other than Brows By Sierrah on the same area (brows, eyeliner, etc) that I am asking Brows By Sierrah to work on today. *Type YES or NO**

4a. IF YES, I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape, and other factors over which Brows By Sierrah has no control. I understand that additional appointments after the initial and follow-up appointments may be required and will be billed at Brows By Sierrah standard rates. I understand that Brows By Sierrah cannot predict the results in advance and cannot guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold Brows By Sierrah harmless from same. *

5. I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. *

6. I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my permanent makeup, and that I must inform any future service provider that I have had microblading applied.. *

6a. I understand and accept that such changes are not the fault of Brows By Sierrah or its employees or contractors. *

6b. I further understand that such changes or degradation in my appearance may not be correctable through further permanent makeup procedures. *

7. I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance. *

8. I acknowledge that obtaining the permanent makeup is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of Brows By Sierrah and its employees and contractors reasonably necessary. *

9. I understand that I will have the opportunity to approve the design and color of the permanent makeup to be applied, and I accept responsibility for same. *

10. I consent to any relevant photographs being taken before, during, and after the procedure, to document the results of the procedure and/or educational purposes for use of Brows By Sierrah. *

11. I consent to Brows By Sierrah using “before & after” photos of me for marketing purposes to display its capabilities and results. *

12. I have been given the full opportunity to ask any and all questions which I have about obtaining permanent cosmetic procedures from a microblade specialist at Brows By Sierrah and that all of my questions have been answered to my full and total satisfaction. *

13. I understand that Brows By Sierrah and its employees are not aestheticians but may need to tweeze a few hairs on my eyebrows to perfect the shape, and authorize Brows By Sierrah to do so. *

14. If you have previously had micropigmentation performed by Brows By Sierrah, has your medical history changed since you last filled out Brows By Sierrah Medical Profile Form? *Type YES or NO* *

14a. IF YES, please specify. *

I have read and understand the contents of each statement above. I acknowledge that this is a contract that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent form I am of sound mind and capable of making independent decisions for myself.

Signature*

Date*

Date

Submit a copy of your photo ID

Permanent Makeup Informed Consent