Client Intake Form for Ombre Powder BrowSign Form Below! Name * First Name Last Name Email * Emergency Contact * Do you currently or have you had any of the following? Please check all that apply: * Autoimmune Disorder Brow/Lash Tinting Chemical Peels Pregnant/Breastfeeding History of MRSA Herpes Heart Condition Aids/HIV Cancer Chemotherapy Depression Hemophila Radiation Cold Sores Cardiac Valve Disease Hepatitis Diabetes Other If you chose "other" please share. Do you wear contact lenses? * Yes No Do have any other allergies? If so, list below. Have you had any of the following surgeries? Blepharoplasty (eyelid surgery) Forehead/Brow Lift Lasik Eye Surgery If so, how long ago was the surgery? Are you taking any medications? Are you taking any blood thinning prescription or non-prescription drugs? Have you had any permanent or semi-permanent makeup services completed previously? Have you had any facial or dermatology services in the past 30 days? Have you used Retin-A, Renova, AHAs or Retinal products in the last three months? Have you received Botox, Lip Fillers, Restylane, Juvéderm or Collagen injections in the last 6 months? Yes No By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health. * * Please check all boxes below. * I certify that I am over the age of 18 years old I have been informed of the nature, risks, and possible complications, and consequences of microshading/ombre powder brows. I understand the semi-permanent cosmetic procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: temporary minor bleeding, bruising of skin surfaces, swelling, redness, temporary discoloration, infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the semi-permanent cosmetic procedure/s and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure/s. I certify that I am not under the influence of drugs or alcohol, I am not pregnant or nursing, and I consent to have the semi-permanent cosmetic procedure listed above performed today. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. I understand that there is a certain level of discomfort associated with the procedure and that each person has their own threshold level for discomfort. Upon consent, my technician may apply topical anesthetics to alleviate discomfort. I understand there is a small chance of an allergic reaction to topical anesthetics. I understand that any skin treatments (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 microshading/ombre powder brows. I understand that sun, tanning beds, pools, some skincare products, and medications can affect my microshading/ombre powder brows. 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 my technician my desire for specific colors, shapes, and positioning for any procedure done today. I understand that after my service, there will be no refunds. No exceptions. I understand that my technician only utilizes sterilized, disposable equipment to minimize the risk of infection or contamination and that my technician has received training inappropriate sanitation and hygiene techniques prior to performing any procedures. While the risk of infection from our procedures is extremely small, the possibility of such an occurrence cannot be totally prevented. Accordingly, I understand and accept the risk and release my technician and the spa from any and all liability related to the subject procedure, except instances involving gross negligence. If I have any signs or symptoms of infections I will seek medical care. Signs of infection include but are not limited to redness, swelling, tenderness of the procedure site, a red streak going from the procedure site towards the heart, elevated temperature, or drainage from the procedure site. I grant permission to ,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, X, TikTok, and Pinterest. I acknowledge that this procedure may alter my appearance and that no representations have been made to me as to remove my microshading/ombre powder brows. 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 microshading/ombre powder brows. 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 before resorting to arbitration, litigation, or some other dispute resolution procedure. I understand that there is a possibility of an allergic reaction to the pigments, anesthetic, or ointments used. 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. A patch test is advisable however it does not ensure I will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to the pigment. Please initial one of the following: I request a patch test, and I understand that a patch test result is not viewed by a medical professional unless I make arrangements to have this done myself. A nonreactive test skin test does not preclude an allergic reaction occurring at a future point in time. I agree to forego a patch test and accept the risk that a reaction is possible. I understand that semi-permanent tattoos may cause Magnetic Resonance Imaging (MRI) artifacts and that there may be a warming and/or tingling sensation in the areas where I received the semi-permanent cosmetic procedure during the MRI due to the iron oxide properties of some pigments. I understand that I should advise my physician that I have microshading/ombre powder brows (a semi-permanent tattoo) in the event I am in need of an MRI. I understand that tattoo inks, dyes, and pigments have not been approved by the Food and Drug Administration (FDA) and that the health consequences of using these products are unknown. I have received pre and post-care instructions and I agree to follow them to the best of my ability. I understand that my failure to follow the pre and post-care instructions may negatively affect my final result. I agree that any touch-up work needed due to my negligence will be done at my own expense. Date * By signing below, I agree to the following: I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this/these procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I accept full responsibility for the decision to have this cosmetic tattoo work done and understand that there is a no refund policy. I acknowledge that I have reviewed and approved the material given to me. * * ***I AM AWARE THAT THIS IS A NON REFUNDABLE SERVICE*** Sign Below. Full Name Thank you!
