Consent and Release Agreement for Semi-permanent Cosmetics

This form provides information to assist in making an informed decision of whether or not to undergo a semi-permanent cosmetics application. If you have questions, please don‘t hesitate to ask. 

Although permanent cosmetic tattooing is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is the process of deposting pigment into the top dermal layer of the skin and is a form of tattooing.

All instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation after an initial application.  It is usual to expect a touch-up after the healing is completed.

Initially the color will appear much more vibrant or darker compared to the end result.  Usually within 5-7 days your brows will lose 25% in thickness and the color will lighten 40-50%, soften and look more natural.  The pigment will fade somewhat over time and will likely need to be touched-up through the years.


POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS

• Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.

• Infection: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas.  See “After Care” sheet for instructions on care. 

• Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes.  Your follow up appointment will likely correct any uneven appearance.

• Allergic Reaction:  If there is any concern for an allergic reaction to pigments, a patch test can be done. However, if a allergic reaction to occur, it may not show up for a long period of time, making the patch test inconclusive.

• Asymmetry: Every effort will be made to avoid asymmetry but our facial features may not be symmetrical so adjustments may be needed during the follow up session to correct any unevenness.   

• Excessive Swelling: Clients with sensitive skin are more prone to swelling. This should dissipate within 24 hours.

• Acne prone: If acne is present on the forehead area, the brows may not heal correctly. If acne is a consistent issue, please consider having semi permanent makeup done is not in your best interest. 

• Anesthesia: Topical anesthetics are used to numb the area to be tattooed.  Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now. 

• MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.


Client Medical History Form

Date *
Date
Birthday *
Birthday
Name *
Name
Address
Address
Phone *
Phone
Do you have any bloodborne pathogen diseases including but not limited to: MRSA, Aids/HIV, Hepatitis(A,B,C,D) *
Diabetes *
Hepatitis (A,B,C,D) *
Aids/HIV *
Hemophilia or any bleeding disorder *
Herpes *
Serious Heart Condition, cardiac valve disease *
Pregnant now/ Breast feeding now *
Autoimmune Disorder *
Have you had cancer within the last year *
Botox within 6 month *
Have you had any surgeries including, blepharoplasty (Eyelid surgery), and Forehead/Brow lift? *
Eye surgery/ injury/lasik eye surgery within 1 year *
Accutane or prescription acne treatment within the last year *
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect. *
Allergies to metals, food, latex, antibiotics. *
Currently on any blood-thinning prescription drugs *

AFTERCARE 

After care is very important for producing a beautiful and lasting result. 

• Keep the area clean by washing with freshly washed hands and a mild soap. Do not use a washcloth or sponge to remove soap. Simply splash with water. Do not use cleansing creams, acne cleansers or astringents. Use a mild, natural soap. 

• Apply the aftercare ointment with a Q-tip. Use the ointment very sparingly. Too little is better than too much. We want your skin to breathe and not clog your pores. Blot off excess ointment with a clean Q-tip.. Never touch the procedure area without washing your hands immediately before. 

• Do not scrub, rub or pick at the epithelial crust that forms. Allow it to flake off by itself. If it is removed before it is ready the pigment underneath it can be pulled out. 

• After the 7 days healing period, always use a sun block after the procedure area is healed to protect from sun fading. Maintaining proper skin care is suggested to help keep your brows as vibrant and fresh as possible. This means cleansing, exfoliating, and moisturizing the brow area is recommended.

• If I have any signs and symptoms of infections I will seek medical care. These include but are not limited to: redness, swelling, tenderness of the procedure site, red streak going from procedure site towards the heart, elevated temperature, or purulent drainage from the procedure site.

 

WHAT’S NORMAL? 

• Swelling, itching, scabbing, light bruising and dry tightness. Ice packs are a nice relief for swelling and bruising. Aftercare balm is nice for scabbing and tightness. 

• Too dark and slightly uneven appearance. After 3-7 days the darkness will fade and once swelling dissipates unevenness usually disappears. The follow-up touch up is highly recommended as any concerns can be addressed.

• Color change or color loss. As the procedure area heals the color will lighten and sometimes seem to disappear. This is normal. The procedure area has to be completely healed before we can address any concerns. This takes at least four weeks. 

• Needing a touch up months or years later. A followup touch up is recommended 6-9 weeks after the initial appointment. Thereafter maintenance may be needed every 12-18 months to keep the shape symmetrical and the color refreshed. 

Failure to follow after care instructions may result in infections, pigment loss or discoloration. 


STATEMENT OF CONSENT AND RECITALS:
  Please read and check all lines

I acknowledge I am age 18 or older *
I will tell all skin care professionals or medical personnel about my permanent makeup procedures. I understand that any skin treatments i.e. Retin A, Renova, Alpha Hydroxy and Glycolic Acids, laser hair removal, plastic surgery, or other skin altering procedures may result in adverse changes to my permanent makeup. I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. *
I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, poor color retention and hyper-pigmentation. *
I accept the responsibility of explaining to you my desire for specific colors, shape, and position for any procedure done today. *
I understand that after my service, there will be no refunds. No exceptions. *
All complimentary followup sessions that are must be done 6-9 weeks from initial session. Failure to make this appointment will incur its corresponding fee.
I understand that implanted pigment color can slightly change in color or in shape and fade over time due to circumstances beyond my artist control. I will need to maintain the color with future applications at my own expense. *
If I have any signs and symptoms of infections I will seek medical care. These include but are not limited to: redness, swelling, tenderness of the procedure site, red streak going from procedure site towards the heart, elevated temperature, or purulent drainage from the procedure site. *
I grant permission to Brow Theory Studios, to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist. *
I acknowledge that this procedure may alter my appearance and that no representations have been made to me as to remove my permanent makeup. To my knowledge I do not have a physical, mental, medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have permanent makeup. *
If a dispute arises out of or relates to this contract, or the alleged breach thereof, and if the dispute is not settled through negotiation, the parties agree first to try in good faith to settle the dispute by mediation within 30 days administered under (name Rules) before resorting to arbitration, litigation, or some other dispute resolution procedure. In the event that parties are unable to agree on a mediator, a mediator shall be appointed by the named administrator. The process shall be confidential based on terms acceptable to the mediator and/or mediation service provider. *
I acknowledge it is not reasonably possible for my technician to determine whether I might have an ALLERGIC reaction to the pigments, anesthetic or ointment used in this process. I agree to forego a patch test and accept the risk that such reaction is possible. *
Notice that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. *
I have read all the Precare guidelines and acknowledge that Aftercare instructions are available on www.browtheorystudio.com. I agree to follow them to the best of my ability. I agree that any touch up work needed, due to my negligence will be done at my own expense. *
I understand the restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with animals, and the duration of the restrictions
Your Name *
Your Name
I certify that I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this procedure(s) and 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. *

Please let us know if you would you like to receive a copy of this statement and consent

Type in your name


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