New Client's Consent Form

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NAME_________________________________________________ DATE________________DOB____________________

ADDRESS______________________________________________________________________________________________

PHONE__________________________________________ EMAIL________________________________________

I, ___________________________________am over the age of 18, am not under the influence of drugs or alcohol and desire to receive the indicated permanent cosmetic procedure.  The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. X_________________

I have been informed of the nature, risks and possible complications and consequences of permanent skin pigmentation.  I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, spreading, fanning or fading of pigments.  I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the procedure(s).  X_________________

I understand that if I have any skin treatment, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics.   I acknowledged some of these potential adverse changes may not be correctable. X___________________

I have received pre-and post-procedure instructions and I will strictly adhere to such instructions.  I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood-altering prescription, I will advise my technician.  If I have ever had cold sores, I will consult with and strictly follow my doctor’s instructions before contemplating any permanent cosmetic procedure around my lips. X_________________

I understand that the taking of before and after photographs of the said procedure(s) is a condition of such procedure(s).  I certify that I have read and initiated the above paragraph and have explained to my understanding this consent and procedure permits.  I accept full responsibility for the decision to have this cosmetic tattoo work done.  

CLIENT_____________________________________________________________ DATE_________________

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I, ____________________________________, acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions I might have about the process of obtaining a tattoo and that all my questions have been answered to my full satisfaction.  I specifically acknowledge that I have been advised of the facts and matters set forth below and agree as follows:

• If I have any condition that might affect the healing of this tattoo. I will advise my practitioner.

• I am not pregnant or nursing, and/or under any influence of drugs or alcohol.

• 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 area to be tattooed that may interfere with said tattoo.  If I have any type of infection, or rash anywhere on my body, I will advise my practitioner.

• I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo, and I agree to accept the risks that such a reaction is possible.

• I acknowledge that infection is always possible as a result of obtaining a tattoo, particularly in the event that I do not take proper care of my tattoo.  I have received aftercare instructions and I agree to follow them while my tattoo is healing. I agree that any touch-up work needed, due to my own negligence will be done at my own expense.  

• I realize that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body.  I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.  

• 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 tattoo.

• I acknowledge that a tattoo, also known as body art, 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 tattoo. To my knowledge, I do not have a physical, mental, or medical impairment or disability, which might affect my well-being as a direct or indirect result of my decision to have a tattoo.

• I acknowledge that tattoo inks, dyes, pigments have not been approved by the Federal Food and Drug Administration (FDA), and the health consequences of using these products are unknown

• I acknowledge that I am over the age of eighteen and that I have truthfully represented to my tattooer and that the obtaining of a tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the tattoo procedure

CLIENT_____________________________________________________________ DATE_________________

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CLIENT MEDICAL HISTORY FORM

Do you have or previously had any of the following: (circle YES or NO)

YES / NO - Botox (Last treatment_________________________________________)

YES / NO - Diabetes

YES / NO - Hepatitis A B C D

YES / NO - Forehead / Brow Lift

YES / NO - Easy Bleeding

YES / NO - Alcoholism

YES / NO - Abnormal Heart Condition

YES / NO - Take medication before Dental work

YES / NO - Chemical Peel (Last treatment_____________________________________)

YES / NO - Pregnant or Breastfeeding

YES / NO - Autoimmune disorder

YES / NO - Oily skin

YES / NO - Cancer (Year_________________________)

YES / NO - Accutane or Acne treatment

YES / NO - Chemotherapy / Radiation

YES / NO - Tan by booth or Salon

YES / NO - Tumors / Growth / Cysts

YES / NO - Difficulty numbing with Dental work

YES / NO - Regular use skincare products containing Retin-A, Glycolic Acid or any Acid

YES / NO - Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin

YES / NO - Allergic reaction to any medication such as Lidocaine, Tetracaine, 

Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin 

Propylene Glycol, Latex

Explain: _________________________________________________________________________________________________

Please list any medications you are currently taking:_______________________________________________

___________________________________________________________________________________________________________

I agree that all of the above information is true and accurate to the best of my knowledge

Signature___________________________________________________ Date_____________________________

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STATEMENT OF CONSENT AND RECITALS: PLEASE READ AND INITIAL ALL LINES

_______ Aftercare instructions have been explained to me and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability.

_______ I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and/or bruising may occur.

_______ I understand that Retin-A, Renova, Alpha Hydroxy, and Glycolic Acid must not be used on the treated areas, they will alter the color and cause premature exfoliation of the pigment.

_______ I understand that tanning beds, pools, some skincare products, and medications may affect my permanent makeup.

_______ I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue.

_______ I will tell all skincare professionals or medical personnel about my permanent makeup procedures especially if I am scheduled for an MRI.

_______ I accept the responsibility to explain to you my desire for specific color, shape and position for any procedure today.

_______ I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 60 days.

_______ I acknowledge that the proposed procedure(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedure(s) such as the following: infection, misplaced pigment, poor color retention, and hyper-pigmentation.

_______ I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention and /or hyperpigmentation.

_______ I have been quoted the cost of today’s appointment and the cost of the touch up via www.browsconcept.com.  Touch-ups must be completed within 80 days of the initial procedure to be considered touch-up price.

_______ I understand that my photos may be taken before and after the procedure, and I approved of Brows Concept to use my photos for any marketing purposes.

_______ I understand there is NO REFUND.

I certify that I have read or have read to me the contents of this form.  I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions and all of my questions have been answered.  I acknowledge that I have reviewed and approved the material given to me, and I authorize Brows Concept to perform on my eyebrows procedure(s) desired today.

Signature___________________________________________________ Date_____________________________________