Name * First Name Last Name Cell * Country (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * The purpose of this form is to provide each client with important information regarding permanent makeup so that they can make an informed decision about the service. This document is a contract and form a legally binding agreement between Luxe Brows and Beauty and the client. Please examine the entire document thoroughly. While the permanent makeup procedure is effective in most cases, like with most permanent makeup/cosmetic procedures, there are no guarantees on the benefits regarding the clients from the procedure and the procedure carries certain risks. Permanent makeup is a process of inserting pigment into the dermal layer of the skin and is considered a form of body art or tattooing. All tools and materials that are used to pierce the skin are sealed prior to use and all other tools used on or around the skin are sealed, sterilized, or sanitized prior to use. The procedure involves risk associated with the procedure and that there is a possibility of complications during and/or after the procedure, including but not limited to: allergic reaction, infection, scaring, inconsistent color, misplaced pigment, hyperpigmentation and spreading fanning or fading of pigment. By signing this document, you are consenting to accept these risks and any other known or unknown risks and as further provided below, no sue, or otherwise attempt to hold Luxe Brows and Beauty responsible for any complications, injuries and or disfigurement result from or related to their services. With that said Krista Jeffery (Hluz) is not a medical professional. If there are any concerns about there being a medical risk associated with the procedure, you need to consult a medical professional to determine whether this procedure will be safe and appropriate for you, including the existence of any medical or skin conditions, medications you are taking and pregnancy. Please be sure to bring up any medical or other condition that you any have reason to believe will affect whether the procedure is appropriate for you, you must bring those concerns up to Krista Jeffery (Hluz) before the procedure is done. Commonly the results of the procedure will be to the client’s satisfaction. However, expectations of perfection are unrealistic, and the results of the procedure will depend on how each person’s skin retains pigment and other circumstances. You should expect to have a touchup session after the initial session’s healing is complete. Brows are not finished until after the second session and healing is complete. Directly after the first session, your brows will be darker and more vibrant than they will be after the healing process is done. You can expect your brow color to fade about 35-45% once they have healed and will have a much natural, softer look to them. The procedure of implanting pigment into the skin is not permanent and you can expect the color to fade over the next 1-2 years, requiring a touchup. ALL SERVICES AND SALES ARE FINAL AND THERE WILL BE NO REFUNDS. Additional information of the permanent makeup procedure is to follow. Please read each statement carefully and initial indicating acceptance. By signing this document, you are certifying your knowledge of and agreement to these terms * I certify that I have read the above information and have had any questions or concerns explained to my full understanding of this consent form and procedure permit. I have had the opportunity to consult with a doctor and/or attorney concerning this agreement and to the extent I have not, that is because I knowingly and voluntarily waived my rights to do so. * Aftercare instructions have been explained to me and a copy has been given to me to retain in my possession, which I will follow to the best of my ability. I understand that if I do not follow these instructions, I may be at an increased risk of the results not being satisfactory and/or may have medical complications of the procedure. * I understand that Retin A, Alpha Hydroxy and Glycolic Acids must NOT be used on treated areas. Use of these products will alter the color and cause premature exfoliation of the pigments. * I understand that tanning beds, pools, and some skin care products and medications can negatively impact my permanent makeup. * I recognize that the tattoo pigment used in the procedure are not approved by the FDA, therefore the consequence of using them are unknown. * I accept responsibility to explain to you my desire for specific colors, shape and position for my brow procedure done 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 touchup session within 60 days of initial application. * I have been advised that a touchup session is highly recommended to adjust shape, color and to fill in any pigment that was lost due to poor retention. I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. Touchups must be completed within 8 weeks of the initial procedure. * I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the necessity to follow those written instructions. * I agree to forever release, discharge, hold harmless Krista Jeffery (Hluz) from any and all lawsuits, liabilities, claims, cause of actions, debts, demands, damages, legal action or equitable action of any kind or nature whatsoever, whether in statute, tort, common law, or contract, including active and passive negligence, arising from or related to in any way to Krista Jeffery (Hluz)’s services, actions, or omissions, including but not limited to my tattoo or the procedure, and conduct used to apply my tattoo and any and all tattoos applied by the tattoo artist, associates, and agents in the future and any physical or medical issues associated with same. I understand that by signing this contract and release, I am voluntarily and consciously waiving and giving up rights I may otherwise have to sue or seek other relief for events occurring in connection with Krista Jeffery (Hluz)’s services. It is my expressed intent that this release shall bind my heirs, assigns, personal representatives and all others who may wish to bring any claim, action, etc. on my behalf. I further agree and acknowledge that there is bargained-for consideration supporting this release and contract generally, including that I am allowed to avail myself of Krista Jeffery (Hluz) in exchange for agreeing to these terms * In any legal action arising from or relating to Krista Jeffery (Hluz)’s services, I agree that the action shall be governed by the laws of the State of California, without regard to conflict of law principles. I further agree that any such action must be brought in Sonoma County Superior Court and that Sonoma County Superior Court is the only appropriate venue for such action. * I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure. I have had the opportunity to ask questions and all of my questions have been answered. I certify that I am 18 years old or older, that I am legally and mentally competent to enter into this legally binding agreement and am not under the influence of drugs or alcohol and there is no other reason I am unable to competently execute this agreement. * I acknowledge that I have reviewed and approved of the material given to me and I authorize Krista Jeffery (Hluz) to perform on my body the permanent makeup procedure desired today. I understand the results are not guaranteed and that this procedure is elective. I agree that this document in not an adhesion contract and that I am signing it of my own free will, that I am not required by medical or any other reason to undergo the permanent makeup procedure and that there are other businesses that provide the same or similar services that I could go to instead of Krista Jeffery (Hluz). I consent to my before and after photos being used for marketing purposes. I waive any right to royalties or other compensation arising from or related to the use of photographic images of me. By signing below, I agree that all the above information is true and accurate to the best of my knowledge and that I agree to the terms above. I am aware that this procedure does not guarantee specific results. Signature * Date * MM DD YYYY Print Name * Ink Color * Ink Lot # * Blaze Size & Lot# * Thank you! MEDICAL QUESTIONNAIRE Name * First Name Last Name Date of Birth * MM DD YYYY Cell * Country (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Occupation * Emergency Contact (Name & Phone #) * Are you at least 18 years of age? * Yes No Are you pregnant or breastfeeding? * Yes No Have you had Botox in the last 2-3 weeks? * Yes No Have you had any chemical peels or laser treatments in the last 6 weeks? * Yes No Have you undergone chemotherapy or radiation therapy in the last year? * Yes No Please list any medications you have taken in the last 6 months: Check any of the following that apply. Accutane or acne treatment Autoimmune disorder Asthma Botox Cancer Cardiac Valve Disease Required to take antibiotics before dental or medical procedures. Taking blood thinners such as: Aspirin, Ibuprofen, etc Tan by booth or salon Hemophilia or other bleeding disorders Herpes at proposed procedure site HIV/AIDS History of MRSA/Staph Infections Keloid Scarring Oily Skin/Sensitive Skin Diabetes Estrogen Therapy Epilepsy Forehead/Brow Lif Hepatitis A B C Tuberculosis Tumer/growths/cyst Allergies: Antibiotics Latex Lidocaine Tetracaine Epinephrine Dermacaine Benzyl Alcohol Carbopol Lecithin Propolene Glycol Vitamin E Acetate Please explain what your goal is for having this permanent makeup procedure done. What are your overall goals? Think in terms of thickness, color, length, higher arch, more even appearance, more filled in appearance, etc.: * Yes No, I consent to having my before and after photos taken for marketing purposes. BY SIGNING HERE, I CERTIFY THAT I AM AT LEAST 18 YEARS OF AGE AND ACKNOWLEDGE HAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Signature * Print Name * Date MM DD YYYY Aftercare: 1. For the first hour, blot eyebrows every 5 minutes with guaze to remove lymph fluid collecting and drying, which will cause scabbing. 2. You should wash your eyebrow for the first time the night of your procedure. You will need to use a gentle, fragrance-free soap with lukewarm and then pat dry with a soft cloth. Do not rub your eyebrows or use anything abrasive on them. If you have quite a bit of natural brow hair you might want to use a blow dryer on a low heat setting to try and get rid of all the moisture. 3. After your eyebrows are dry apply a fragrance free, water-based lotion or cream to your tattoo. Avoid using petroleum-based products as they can clog pores and cause irritation. 4. You will continue that process morning and night for 10 days or until the tattoo heals-whichever occurs first. 5. Avoid submerging your tattoo in water, such as swimming pools, hot tubs, or baths for 2 weeks. 6. Avoid direct sunlight and tanning beds until your tattoo is fully healed. 7. Avoid picking scabs or peeling skin as that can cause scarring and change the outcome of the color. 8. If you have any questions about the healing process, please contact your tattoo artist or a medical professional. Signs of tattoo infection: While some redness, swelling and mild discomfort after your service are normal, please look out for symptoms below that could mean a sign of infection. They are: 1. Increased pain or discomfort. 2. Redness that spreads beyond the tattooed area. 3. Swelling that worsens over time. 4. Pus or other discharge that comes out of the tattooed area. 5. Unpleasant odor. 6. Fever or chills. If you suspect that your tattoo is infected, please seek medical attention right away. Your healthcare provider can diagnose and prescribe antibiotics or other medication. It is also important to follow the proper aftercare to ensure that your tattoo heals correctly Thank you!
