Eyebrow Semi Permanent Make-up Form

EYEBROW SEMI PERMANENT MAKE-UP FORM

Please read all terms and condition before filling the form

Please read the following advice carefully and fill the form at the end

Eyebrow semi-permanent make up procedure normally requires multiple treatment sessions. For best results, clients will be required to return for at least one re-touch appointment. This will take place 2 month after the initial procedure. Please be aware that color intensity will be significantly darker and sharper immediately and a few days after the initial procedure, but the color will reduce by 30%

Although numbing cream is used during the procedure, sensitivity or discomfort may still be felt. Skin may be red and/or swollen after the procedure

Please do not drink alcohol 24 hours prior to the treatment

Please do not shape or wax your brows before the procedure. Your technician will shape brows during the procedure

No electrolysis for at least 5 days before the procedure

Botox, AHA products and retinoid should be avoided for 2 weeks prior to the procedure

Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure

Chemical and laser peels should be avoided no less than 6 weeks prior to procedure

Patients prone to cold sores/fever blisters should take an anti-viral prior to treatment

Hormone therapies can affect pigmentation and/or cause sensitivity

Topical Anesthetic Advice
Allergic reaction can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.

Numbness - We cannot accept responsibility if the area to be treated does not respond to the numbing cream. Each individual is different according to skin type. Some clients report the area to be completely numb, while others may experience some discomfort.

Procedure - For Eyebrow semi-permanent make up a numbing cream/gel is used. The products are formulated to be perfectly safe and can be purchased over the counter from any pharmacy/chemist. The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness/swelling that can last 1-4 days. You should always follow your post procedure advice and after care for the best results.

Contraindications for Eyebrow semi-permanent make up
Liver disease - high risk of infection - Compromised skin near brow area - Pregnancy / Nursing - Chemotherapy / Radiation

The following medical conditions require a note from your doctor giving consent Diabetes Type 1 and 2, high blood pressure, auto-immune disease, thyroid / Graves' disease Any other medical condition that causes slow healing or a high risk of infection

I have read and fully understood the above information provided and any risks involved with the use of topical anesthetic and I therefore consent to the use of the anesthetic for the micro blading procedure. I agree to follow pre-procedure and post-procedure advice closely

I accept all the Terms and Conditions

Eyebrow Semi-Permanent Make Up & Policies & After Care Instructions

- Scheduled appointments for the touch up procedure require 48 hours’ notice for cancellation or rescheduling.
- If marked as a cancellation your deposit will not refunded.
- Cancellation will be considered as day of scheduled appointment, no shows, no contact, or changing of the mind once you show up to scheduled appt.
AFTER CARE INSTRUCTIONS

Please follow these instructions for 10-14 days after the procedure to improve and prolong the results of Your Brows. If you don't follow these instructions, it can greatly affect your Hair Stroke Machine results!

I have applied a liquid barrier that will stay on and protect your brows. Avoid getting anything on the brows except for cleansing as directed. You may blot for the first few hours with sterile gauze to remove any excess fluids, if necessary.

Do not attempt to remove the barrier film if it was applied. Allow it to come off naturally it is own time. Do not pick or rub the brows. The flakes must falloff on their own or you will risk removing the color and possibly scarring.

Do not soak the treated area in the bath, pool or hot tub. For 30 days, refrain from swimming in saltwater or chlorinated pools, saunas, hot yoga, steam rooms or sun beds.

No exercise for 3 days. After 3 days - when exercising, wear a sweatband to avoid sweat on brow area.

Do not expose treated area to direct sunlight. After healed (30 days), use a sunscreen to avoid fading from the sun.

No makeup should be applied directly on the brows during the healing process.

Do not touch, rub, pick or scratch your brows following treatment or during healing process.

You may find that your eyebrows will scab or become slightly dry following the treatment. If they itch, DO NO SCRATCH them.

You may tap them to alleviate the itch.

If your eyebrows get wet during the healing process, pat them dry with a towel, DO NOT RUB.

Avoid using daily skincare products directly on the eyebrows.

If you are planning a chemical peel, or any other medical procedure, please inform therapist of the procedure you have had. Procedure should only be done once the healing process is complete.

If you are due to give blood after the procedure, please inform your nurse about the micro blading treatment you have had as this might alter the results.

Email me with any questions or concerns- kittayaroyalbrow@gmail.com

To book your retouch appointment visit me on my website www.kittayaroyalbeauty.com or message me Facebook page kittayaroyalbrow.com or you can also Instagram me @kittayanelson

DON’T FORGET TO SCHEUDLE YOUR RETOUCH 6-9 WEEKS AFTER FIRST SESSION BUT NOT LONGER THAN 6 MONTHS.

I accept all the Terms and Conditions

INFORMED CONSENT FOR EYEBROW SEMI-PERMANENT MAKE UP

I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated semi-permanent pigmentation procedure. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed, has been explained to me.

If an unforeseen condition arises in the course of the procedure, I authorize my therapist to use her professional judgment to decide what she feels is necessary under the given circumstances. I accept the responsibility for determining the color, shape and position of the Hair Stroke Machine procedure as agreed. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 2-3 years. Even once the color fades, pigment itself may stay in the skin indefinitely.

I have been informed that the highest standards of hygiene are met, and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit.

I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeated procedure.

The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), and personal pH balance of your skin, alcohol intake and smoking, post procedure after care.

Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed. Please see after care instructions for more details. The procedure results will look acceptable for you to appear in public without additional make-up on the brows.

I have been advised that the true color will be seen 6 weeks after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.

To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well-being as a direct or indirect result of my decision to have the procedure done at this time.

I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure. I can confirm that I have received a copy of aftercare details.

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, scarring, inconsistent color, and 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 semi-permanent skin pigmentation procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences of the said procedure (initial)

There is a possibility of an allergic reaction to numbing agent and/or pigments. A patch test is offered however it does not ensure a client will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to the pigment. Initial one or the other not both:

I understand that if I have any skin treatments, injectable, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my micro blading procedure. I acknowledge some of these potential adverse changes may not be correctable. (Initial)

I certify that I have read and initialed the above paragraphs and have had explained to my understanding the consent and procedure permit. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.

Yes, I give Kittaya Royal Beauty permission to perform my Eyebrow semi-permanent make up procedure.

I accept all the Terms and Conditions

Eyebrow Semi-Permanent Make Up Machine Disclosure & Release Form

I understand the following completely: (initial each statement)

- Eyebrow semi-permanent make up can last 2-3 years depending on how my skin reacts to the procedure. There may be fading and/or discoloration. The result may not be what I expected to receive. I understand this is a semi-permanent makeup procedure that may take numerous follow-ups and touch ups to get desired result.

- I must schedule the touch up for 2 to 3 months after my initial treatment but no later than 6 months from first session. If longer than 6 months touch up will not be as priced. 1 have read and understand the Fees & Policies sheet.

- There is no warranty or guarantee made to me as a result of this procedure and the final result cannot be guaranteed. There are no refunds for this procedure, as results will vary, and individual results are not guaranteed.

- I have seen and agree with the pre-draw shape that my artist created. I understand that this is a guideline for the shape and size of my brow design, and it may vary slightly once the procedure is done.

- There may be risks and hazard related to performing this procedure.

- There may be discomfort and pain during this procedure.

- There is a possibility of swelling, redness and allergic reactions to pigments.

- Eyebrow semi-permanent make up is considered semi-permanent and can/will fade over time.

- Eyebrow semi-permanent make up though semi-permanent, may last permanently and may not fade.

- Surgical procedures may be required to remove pigment from skin. These procedures may cause scarring and permanent damage to the skin.

- Final result cannot be determined until brows are completely healed at 6 to 9 weeks.

- I understand that permanent and semi-permanent makeup procedures cannot be guaranteed, and results cannot be predicted, as there are many variables that contribute to the final result, such as aftercare, skin type, lifestyle, etc.

- I have received post care instructions and will follow them to ensure results of my procedure are satisfactory.

- I am NOT pregnant

- I am NOT under the influence of drugs and/or alcohol or any other mind-altering substance

- I fully understand the procedure and give permission to my technician to perform the service of Micro blading and all procedure and steps involved.

- I have truthfully filled out the consent form and have informed my technician of all medications 1 have taken.

- I release Kittaya Royal Beauty, LLC and its representatives and license technicians of all claims and injury, seen or unseen that may occur as a result of this procedure.

I accept all the Terms and Conditions

If Yes, Contact your physician for a preventative prescription capsule to prevent a cold sore.

Yes No

Are you currently taking medication that thins the blood?

Yes No

Are you currently under the care of a physician? If yes, please explain:

Physician's Name

Do you take antibiotics when going to the dentist? If yes, why?

Have you ever had one of the following (Please Select)?

Hair Loss Trichotillomania Hemophilia Liver Disease Thyroid disturbances Anemia Epilepsy HIV Alopecia Cancer Sensitivity to Cosmetics Artificial Heart Valve Fainting Spells or Dizziness Tumors, Growths, Cysts Healing Problems Prolonged Bleeding Low Blood Pressure Circulatory Problems Botox / Filler Injections Do you Scar Easily? Diabetes High Blood Pressure Hypertrophic or Keloid Scars Hepatitis Do you Bruise / Bleed Easily?

What would you like to improve about your eyebrows? Consider shape, color, density, thickness .

Please read the following statements carefully. Eyebrow semi-permanent make up is a way of cosmetic tattooing, intended to be semi-permanent lasting average 2-3 years. On a rare occasion, the pigment may migrate under the skin. Procedure of Eyebrow semi-permanent make up may be uncomfortable. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be performed if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after Eyebrow semi-permanent, make up you should notify/discuss with your doctor. Possible scarring may occur. I have received after care information and I'm fully aware of the aftercare procedures. I fully understand the information provided above & confirm that all information provided by me is correct and truthful.

I accept all the Terms and Conditions