PMU Consent Form

Name

First NameLast Name

Email

example@example.com

Street Address

Street Address Line 2

City

State Province

Postal Zip Code

Phone

Please enter a valid phone number

Date Of Birth - must be 18 years or older

Date

Please put the date of your scheduled appointment

Date

What type of Services or procedure are you receiving?

Stroke Nano BrowsConsultation

Are you currently pregnant or nursing?

YesNo

Do you have previous work done on your brows? (if yes please provide a well lit picture of your brows below)

YesNo

Carga de archivo

Please Upload a picture on the front of your ID

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 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. By checking the boxes below, I specifically acknowledge thatI have been advised of the facts and matters set below, and I agree as follows: (Please check the box next to the statement after you clearly understand each statement and agree to each statement)

I acknowledge that complications as a result of permanent makeup procedures may occur, particularly in the event that the pre and post- procedural instructions are not followed, and accept full responsibility for such complications.I realize that my body is unique and neither Jeany Beauty Studios LLC nor its employees or contractors can predict how my skin may react as a result of the procedure.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.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 permanent cosmetics applied. I understand and accept that such changes are not the fault of Jeany Beauty Studios LLC or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further permanent makeup procedures.I understand that Jeany Beauty Studios LLC and its employees are not aestheticians but may need to tweeze a few hairs on my eyebrows to perfect the shape. I authorize Jeany Beauty Studios LLC and its employees to do so.I understand that if I have MRSA (Methicillin-resistant Staphylococcus Aureus) infection I will need to communicate that with Jeany Beauty Studios LLC and its employees.Jeany Beauty Studios LLC will need to take before, after, mapped, and more pictures and videos for educational, marketing, and insurance purposes.I acknowledge that permanent makeup- Brows, Lips, and Eyeliner require a minimum of 2 appointments to get the desired results. Brighter/ Bolder results may require more touch-up appointments. Eunoia Studios LLC is not at liberty to provide discounted, or free services.

I agree and acknowledge all of the above.

The following statement is your Pre-Care instructions

HOW DO I PREPARE FOR MY APPOINTMENT?

FOUR WEEKS before your appointment please stop the use of all retinols and retin-a and do not receive any chemical peels. Why? Retinol, retin-a, and chemical peels cause the skin to thin and turn over quicker which makes it extremely delicate and sensitive.

TWO WEEKS before your appointment please do not receive any Botox or Dysport injections. Botox can take up to 14 days to kick in and we want to be able to work with the final result of your injections. I will also be in contact with your forehead and brow area and this can affect the results of your Botox, and trust me, no one wants that! Please wait to schedule injections either 2 weeks before or 2 weeks after your brow appointment. For lip filler, chin jaw, cheek filler, or Botox please wait 2-4 weeks before and after your appointments. Avoid excessive sun exposure, we will not be able to work over skin with any degree of sunburn and we will have to reschedule. Stop waxing, tweezing, or tinting your brows a couple of weeks before your appointment. This will give me an accurate idea of your natural shape and growth and will allow me to give you a natural result.

TWO DAYS before your appointment please stop the use of any blood thinners such as aspirin, niacin, vitamin E, fish oil, coq10 and ibuprofen. Many supplements and medications thin the blood, so I urge you to research what you are currently taking and make sure they are not blood thinners. Why? Blood thinners cause you to bleed more. Bleeding during the procedure not only makes it difficult for the artist but can also affect your retention of the pigment and can cause the pigment to heal an ashy tone. Please consult your doctor before stopping any medications.

TWENTY FOUR HOURS before your appointment please do not consume any caffeine, alcohol, or smoke cigarettes. These substances may cause excessive bleeding by either thinning the blood or elevating your blood pressure. Again, this makes it difficult for the artist and will affect your retention. If I am not able to work with the level of bleeding, we will need to reschedule your appointment. Don't exercise on the day of your appointment. This will also raise your blood pressure and heavily affect the level of bleeding.

THE DAY OF YOUR APPOINTMENT it is a good idea to come with freshly washed hair. After your procedure you will need to keep your brows/ lips/ eyes dry as long as possible and that can make it difficult to wash your hair. We will also be taking lots of photos so come how you feel the most confident and comfortable.

WHAT SHOULD I EXPECT AT MY APPOINTMENT?

The first thing we will do is go over this consent form to ensure that you have followed all pre-care and understand the expectations, risks, outcomes, and benefits of permanent makeup. After we have checked the above off we will follow with Pre-appointment pictures. These pictures are REQUIRED for my insurance. Once finished with pictures we will start to map the area(s) of the procedure.

BROWS- we will map out your brows with a red and black china pencil to perfect the shape on your face.

When choosing a color for brows or eyeliner it is important that you understand we will want to have the color be 1-2 shades warmer than the end goal color. This can often scare clients to see an orange undertone, please rest assured this will NOT be the healed shade. WHY DO I WANT ORANGE IN MY COLOR? The face skin is going to have the most cell turnover rate due to the amount of exfoliating, exposure to the sun, skincare, and sweating. Naturally, over time, the cells will turn over and as they do, the molecules that make up the color will also start to turn over. The first molecule to turn over is our yellow and red molecules, leaving behind blue and sometimes even black. This is where you will see the 'ashing/grey-ing out' of the brows. My goal is to create a color that allows your brows to age/and fade out beautifully over the years with little to no 'ashing'. The orange undertones support the additional loss of yellow/red molecule loss during the first 12-24 weeks of healing time.

Once color and shape have been given the approval by the artists and client we will continue to the appointment-from this point, you should expect at least 2-3 hours of procedural time. You will be numbed throughout the ENTIRE session. During this time I may ask to keep talking to a minimum as some movements depending on the procedure area(s) may limit me from doing the procedure. The client can bring a blanket, some headphones, and anything that may bring you comfort.

I encourage all clients to dress comfortably, some appointments take up to 4 hours so your comfort is my priority. The best colors to wear are black, Dark Brown, and Navy Blue. Any crazy colors like red, pink, green, orange, or purple may cause a shadowing of color on the face. This can cause pictures to look off, and to affect the look of the color on your skin under the light. If you choose to take off your shoes please bring socks to wear while lying down. Please avoid Hoodies or large collared shirts as they can cause neck pain while laying on down.

WHAT TO BRING TO THE APPOINTMENT:

The salon can get cold, you are welcome to bring a blanket if you get cold easily.

Headphones: once we begin tattooing I ask that conversations be paused so I can provide the BEST work, this means that clients can get bored. Please bring headphones to listen to music or your favorite podcast.

Makeup: IF you wear makeup to your appointment please bring backup because it will get smeared off. I will take before and after pictures and want you to feel amazing!

Once your procedure(s) are done we will take pictures, talk through aftercare, and get you booked for a 6-10 week touch-up.

Brows appointments REQUIRE a follow-up appointment for full desired results. All touchups take place 6-12 weeks post-initial appointment. Please be attentive to booking this post-initial appointment to ensure a spot-on Jeany Beauty Studios schedule.

Please check the box for yes to the statement - leave the box empty for no

18 years or olderOn accutane or have been in the last yearUndergoing chemo therapy or have in the last year Allergic to Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene, Glycol, Vitamin E, Acete, etc. (if yes leave list below)Allergic to metals - (needles)Botox, fillers, planned in the next 3 monthsEasy bleederCancers, tumors, or cystsUse of blood thinners such as; Aspirin, Ibuprofen, Alcohol, Coumadin, Fish Oil, etc.Hyperthyroidism Hypothyroidism Difficulty numbing (ie; at the dentist) Lupas or Hemophilia

The patron form shall inform the patron of risks associated with body art procedures such as the risk of fainting vomiting and infection including bacterial endocarditis for patrons with a heart condition.

If yes, please list allergies here.

Are you currently using any prescribed or non prescribed medications, please list below.

Any disorders or diseases not listed above.

I have read and understand the contents of each statement above. I acknowledge that this is a contract and 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 I am of sound mind and capable of making independent decisions for myself.

Sign Here

1. GUEST POLICY- For safety and focus, guests are not allowed during your appointment. This includes partners, children, pets, parents, or siblings. The salon must remain distraction-free as your procedure involves tattooing the face and typically lasts around 4 hours. Please ensure your loved ones are aware of this time commitment.

2. MEDICAL CIRCUMSTANCES- If you require medical assistance or have a service animal (not including emotional support animals), please contact the artist beforehand. Since the salon operates on an open floor plan with other artists and clients, we aim to provide a safe, sterile, and distraction-free environment. To accommodate your needs, we may schedule your appointment on a day when the salon is closed and allow additional time if necessary. Please notify the artist as soon as possible to make appropriate arrangements.

3. DEPOSIT/RETAINER FEE- Deposits or retainer fees are nonrefundable and applied toward your appointment total. If you cancel, reschedule, or fail to show up, the fee will be forfeited. Please review the cancellation, rescheduling, and no-show policies for more details on applicable fees.

4. RESCHEDULING POLICY- Life happens, and sometimes appointments need to be rescheduled. Clients are encouraged to book appointments after major events or busy weekends to minimize rescheduling. Please provide at least one week's notice when rescheduling. If rescheduling within a week of the appointment, fees may apply. Clients are allowed two reschedules. After a third reschedule, the appointment will be considered canceled, and the deposit forfeited. Rebooking will require a new nonrefundable deposit of 50% of the appointment total.

5. CANCELLATION POLICY- Cancellations result in the forfeiture of the nonrefundable deposit/retainer fee. Clients are required to give at least one week's notice for cancellations or rescheduling. Cancellations made within 1 week to 24 hours of the appointment will incur a fee of up to 50% of the appointment total. Same-day cancellations are considered last-minute and will be charged up to 100% of the appointment total.

6. LATE POLICY- If you are running more than 10 minutes late, please contact the artist immediately. Clients arriving more than 15 minutes late without prior notice will be considered a "no-show" and subject to the no-show policy. If you contact the artist within 10 minutes of being late, you may be asked to reschedule depending on the time available.

7. NO-SHOW POLICY- No-shows are unacceptable. A no-show occurs when a client fails to cancel or notify the artist of their absence. No-shows will be charged 100% of the appointment total. Rebooking after a no-show requires a new 50% nonrefundable deposit/retainer fee. Clients failing to confirm their appointment one week prior risk losing their deposit. Jeany Beauty Studios LLC reserves the right to deny service to anyone who no-shows.

8. PAYMENTS- Payment is due immediately upon completing the service. Accepted payment methods include cash, card, or Afterpay. Venmo, Zelle, CashApp, and similar platforms are not accepted. Leaving the salon without paying is considered theft and will be reported to authorities. Unpaid balances will incur a 1% daily interest charge until resolved.

9. REFUND POLICY- All payments are final and nonrefundable. As a service-based business, clients agree to this policy once the service is completed.

By signing you agree to having read precare and policy and you understand and agree to all precare and policies.

How did you hear about Jeany Beauty Studio?

PMU Consent Form

JEANY BEAUTY STUDIO LLC

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