Semi-Permanent Brows Consent Form

( MICROPIGMENTATION )

• I am currently under the care of a physician
• If you are under the care of a physician, please explain your medical condition in the space below:
- I am pregnant or nursing
- I am taking aspirin
- I use skin thinners

I suffer from:

• Allergies
• Heart problems
• Diabetes
• Hemophilia
• Keloids
• Moles or freckles at the site of the procedure
• Epilepsy

*Indicate Below

• I understand that to secure my semi- permanent service I need to pay in advance a $150 deposit.
• I understand that the deposit is non-refundable
• I accept that I need to schedule and pay for a semi- permanent consultation before my actual application.

*Initial Below

• I accept the responsibility to fully explain to my artist of the specific color, shape and position I desire for the procedure today.
• I understand that there may be a certain amount of discomfort and pain associated with the procedure
• I understand that the practitioner cannot fully predict the results in advance and cannot guarantee that the results will be as I desire.
• I have reviewed the list of Contraindications attached to this Consent Form
• I understand that if I undergo any skin care procedures, that it may negatively impact maximum results.
• I understand the Post Operative Care instructions set out below and I will strictly adhere to such instructions. I understand that my failure to do so will negatively impact the sought after results from the procedure.
• I understand that a minor amount of temporary bleeding, redness, discoloration, swelling and bruising is normal following this procedure and it should resolve itself within a few days following treatment.
• I understand that the implanted pigment color can slightly change or fade over time, and I will need to maintain the color with future touch up sessions. I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any areas that may have had poor retention. Touch-ups must be completed within 30 days or initial procedure for best results.

*Post Operative Care Instructions*

• Preparation Prior to Procedure
• Do not consume
- Alcohol (24 hours before)
- Aspirin/Ibuprofen (24 hours before)
- Caffeine (5 hours prior)
• Discontinue use for the time periods indicated prior to procedure
- Retinol/ Vitamin A (1 month)
- Latisse (2 months)
- Botox (1month)
- Chemical peel/ facial (2 weeks)
- Intense sun exposure/ Sunburned skin (4 weeks)

• Semi- permanent brow after care:

- Do not get the brow area wet for the next 7 days as it heals (minor splashing is fine, but no prolonged exposure to water)
- Pat to dry brow area
- No makeup application on the brows, until brows heal (length depends on your healing process)
- No excess sweating: swimming, sunbeds, sauna, gym, hot yoga, steam face, and steam bath until your brows heal (length depends on your healing process)
- No soap, moisturizer, makeup, creams or sunscreen on the brow area until it heals (length depends on your healing process)
- Hot water can irritate the treated area
- Do not use any type of cleansing product for 7 days after service
- Avoid smoking and drinking alcohol for 3-5 days after service
- Do not rub or pick at the dry flaky skin/ scab
- Apply a thin layer of healing cream given by your technician if it feels itchy or if the scabs look really dry and flaky (maximum application is no more than twice a day)
- Do not use Polysporin or Vaseline as healing cream, any use of antibiotic ointments will speed up the healing process and affect the colour of the pigment.
*The second touch up can be done after 6 weeks and within 2 months, additional cost occurs after 2 months*

*Initial Below

• Discomfort, even with the use of topical anesthetics. Clients who are menstruating may be more sensitive.
• Infection
• Allergic reaction
• Misplaced pigment
• Poor color retentiona
• Hyper pigmentation

I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure, and agree to accept the risk that such reaction is possible.

*Initial Below

This agreement will remain in effect for this procedure and all future procedures conducted by any stylist at Pretty Little Secrets Lash & Brow Bar. I release my stylist and Pretty Little Secrets Lash & Brow Bar from all liability associated with this procedure. I understand the practitioner does not practice medicine and does not accept health insurance, and had made no representation of the contrary.

I certify I have read and understood the above paragraphs and have had it explained to my understanding. I accept full responsibility for the decision to have this cosmetic work done.
I understand the information provided on this form is accurate and complete to the best of my knowledge, and the practitioner is not responsible for complications or problems arising from any incorrect or omitted information.

By signing below, I verify that I have fully read and understand all the information provided in this agreement, Contraindications form and Post Operative instructions. I am over the 18 years of age or consent to the agreement. I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself.

By signing below, I verify that I am over 18 years of age and have read, understand and agree to everything contained in this consent form, the Contraindications and the Post Operative care instructions.
If under 18, the parent or guardian of the client must sign here.

*Signature & Date Below

I give permission to take before and after photos of my eyes/ face which may be used for any type of marketing purposes (website, brochures, business cards, salon or class, etc).

If under 18, the parent or guardian of the client must sign here

*Signature & Date Below

Booking and Cancellation Policy

To confirm your appointment a $150 non-refundable deposit is required at the time of your booking. Please note that once you have booked an appointment with us it means that we have reserved time in our schedule exclusively for you. If you cancel your appointment less than [24 hours] before it is scheduled to take place, your deposit will be forfeited. To avoid forfeiting your deposit, please provide cancellation notice at least [24 hours] prior to your appointment.