BROWS BY BRIN
CLIENT CONSENT FORM
1. CLIENT INFORMATION
FULL NAME:
*
DATE OF BIRTH:
*
-
Month
-
Day
Year
Date
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:
*
Format: (000) 000-0000.
EMAIL:
example@example.com
PREFERRED CONTACT:
CALL
TEXT
EMAIL
2. EMERGENCY CONTACT
NAME:
PHONE NUMBER:
Format: (000) 000-0000.
RELATIONSHIP:
3. SKIN CONCERNS & BROW GOALS
HOW DID YOU HEAR ABOUT BROWS. BYBRIN?
4. MEDICAL HISTORY
Please check any that apply:
Medical Conditions
Pregnant or breastfeeding
Diabetes
Autoimmune disorder
Cancer / Chemotherapy
Hepatitis (A, B, C, D)
Heart condition
Easy bleeding / Bruising
Blood thinner medication
Recent Botox (within 2 weeks)
Recent fillers (within 2 weeks)
Recent chemical peel (within 2 weeks)
Accutane (within the last 12 months)
Retinol / Retin-A / Exfoliating acids
Oily skin
Allergy to numbing agents
Metal allergies
Difficulty numbing
Previous permanent makeup
MRSA
Other
5. INFORMED CONSENT
Please initial each statement:
I have disclosed my complete medical history, medications, allergies, and skin conditions.
*
I understand corrections of previous work by another artist may require additional appointments and results cannot be guaranteed.
*
I understand permanent makeup is an elective cosmetic tattoo and results vary from person to person.
*
I approve my brow shape and color before beginning the procedure.
*
I understand that perfect symmetry is not always possible.
*
I understand multiple appointments may be required and healed results cannot be guaranteed.
*
I consent to photographs being taken for documentation.
*
I understand pigment may fade or change over time due to skin type, lifestyle, sun exposure, medications, aging, or future cosmetic procedures.
*
I have had the opportunity to ask questions and all of my questions have been answered.
*
I understand that failure to follow aftercare instructions may negatively affect my results.
*
6. PHOTO RELEASE
Photos may be taken before, during, and after your procedure for documentation.
Photo Release Options
*
YES, I authorize brows.bybrin to use my before-and-after photos for marketing purposes.
NO, I do not authorize brows.bybrin to use my photos for marketing purposes.
Your privacy will always be respected.
7. AGREEMENT & SIGNATURE
By signing below, I acknowledge that I have read and understood this form. I agree to the procedure, risks, and responsibilities outlined above and will follow all aftercare instructions.
CLIENT NAME (PRINT)
*
DATE
*
-
Month
-
Day
Year
Date
CLIENT SIGNATURE
*
DATE
*
-
Month
-
Day
Year
Date
PARENT / GUARDIAN (IF UNDER 18)
DATE
-
Month
-
Day
Year
Date
ARTIST SIGNATURE
DATE
-
Month
-
Day
Year
Date
THANK YOU FOR TRUSTING ME WITH YOUR BROWS! CANT WAIT TO SEE YOU IN MY CHAIR!
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