top of page
browhouse6464.jpg

CONSENT FORM

BROWHOUSE CONSENT FORM
arrow&v

SERVICE PRECAUTIONS 

PLEASE READ CAREFULLY, CHECK ALL BOXES AND SIGN BELOW:

I AM AWARE I WILL BE NUMB FOR APPLICABLE SERVICES BUT MAY EXPERIENCE SLIGHT SENSITIVITY AND/OR DISCOMFORT. DELICATE OR SENSITIVE SKIN MAY EXPERIENCE REDNESS AND/OR SWELLING DIRECTLY AFTER THE PROCEDURE.  

NUMBNESS & ALLERGIC REACTION:

NUMBNESS: WE CAN NOT 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.

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.




PRE-CARE:

I HAVE NOT RECEIVED BOTOX IN THE PAST TWO WEEKS AND/OR THE PAST WEEK FOR REGULAR BOTOX CLIENTS. (BROWS) 

I HAVE NOT RECEIVED FILLER IN THE PAST TWO WEEKS. (LIPS)

I HAVE NOT RECEIVED A CHEMICAL OR FACIAL PEEL IN THE PAST TWO WEEKS. (BROWS).



 

HEALTH QUESTIONNARE

arrow&v

I ACKNOWLEDGE THAT OBTAINING PERMANENT MAKEUP IS MY CHOICE, AND THE APPLICATION OF PERMANENT MAKEUP WILL RESULT IN A PERMANENT CHANGE TO MY APPEARANCE AND THAT NEEDLES AND INK WILL GO INTO MY SKIN. NO REPRESENTATIONS HAVE BEEN MADE TO ME AS TO THE ABILITY TO LATER RESTORE THE SKIN INVOLVED IN PERMANENT MAKEUP TO THE ORIGINAL CONDITION, AND IT IS VERY COSTLY TO REMOVE.

I AM NOT PREGNANT OR NURSING. I DO NOT HAVE ANY HISTORY OF HERPES INFECTION AT THE PROPOSED PROCEDURE SITE. I DO NOT HAVE EPILEPSY, DIABETES, ALLERGIC REACTION TO LATEX OR ANTIBIOTICS, HEMOPHILIA OR ANY OTHER BLEEDING DISORDER. I DO NOT HAVE CARDIAC VALVE DISEASE OR SUFFER FROM ANY HEART CONDITIONS OR TAKE MEDICATIONS THAT THIN MY BLOOD.

IF I SUFFER FROM HEPATITIS OR OTHER RISK FACTORS FOR BLOOD-BORN PATHOGEN EXPOSURE, OR ANY OTHER COMMUNICABLE DISEASE, I HAVE INFORMED THE TECHNICIAN OF THE FACT. I HAVE BEEN ADVISED OF ANY MEDICATIONS AND PROCEDURES NECESSARY TO PROMOTE THE SATISFACTORY HEALING OF MY TATTOO.

I DO NOT SUFFER FROM ANY MEDICAL OR SKIN CONDITIONS SUCH AS, BUT NOT LIMITED TO: KELOID OR HYPERTROPHIC SCARRING, PSORIASIS AT THE SITE OF THE PERMANENT MAKEUP, OR ANY OPEN WOUNDS OR LESIONS AT THE SITE OF THE TATTOO.

I DO NOT HAVE A HISTORY OF MEDICATION USE, OR AM I CURRENTLY USING MEDICATION, INCLUDING PRESCRIBED ANTIBIOTICS BEFORE DENTAL OR SURGICAL PROCEDURES. ANY AND ALL MEDICAL CONDITIONS REQUIRE PHYSICIAN APPROVAL FOR ANY SERVICE. IT IS THE CLIENT'S RESPONSIBILITY TO OBTAIN THIS APPROVAL, AND THE BROWHOUSE IS NOT RESPONSIBLE IF SAID CLIENT HAS NOT DONE THEIR RESEARCH AND/OR RECEIVED THE PHYSICIAN'S APPROVAL.

I HAVE ADVISED THE TECHNICIAN OF ANY ALLERGIES TO LATEX GLOVES, SOAPS, OR MEDICATIONS. I ACKNOWLEDGE IT IS NOT REASONABLY POSSIBLE FOR THE TECHNICIAN TO DETERMINE WHETHER I MIGHT HAVE AN ALLERGIC REACTION TO THE PERMANENT MAKEUP PROCESS AND FURTHER ACKNOWLEDGE THAT SUCH A REACTION IS POSSIBLE. 

 

I TRUTHFULLY REPRESENTED TO THE TECHNICIAN THAT I AM 18 YEARS OF AGE OR OLDER. I AM NOT UNDER THE INFLUENCE OF ANY DRUGS OR ALCOHOL. 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 A TATTOO AT THIS TIME. 

 

I ACKNOWLEDGE THAT INFECTION IS ALWAYS POSSIBLE AS A RESULT OF PERMANENT MAKEUP APPLICATIONS, AND I AGREE TO FOLLOW ALL SUGGESTED INSTRUCTIONS CONCERNING THE CARE OF THE PERMANENT MAKE-UP SITE WHILE IT IS HEALING.

 

 

 

I ACKNOWLEDGE AND GIVE CONSENT TO THIS PERMANENT MAKE-UP STUDIO TO USE IMAGES OF MY TATTOO(S) FOR MARKETING AND, OR PUBLISHING PURPOSES IN VARIOUS MEDIA SUCH AS THE INTERNET, MAGAZINE, PRINTED, AND OR TELEVISION ETC. 

 

I UNDERSTAND I WILL HAVE PERMANENT MAKEUP APPLIED USING APPROPRIATE INSTRUMENTS AND STERILIZATION TECHNIQUES. I UNDERSTAND THAT THE PERMANENT MAKE-UP SITE USUALLY TAKES 2 WEEKS OR LONGER TO HEAL. I AGREE TO RELEASE AND FOREVER DISCHARGE, AND HOLD HARMLESS, THE TECHNICIAN, ALL EMPLOYEES, CONTRACTORS, AND THE MANAGEMENT OF THE PERMANENT MAKE-UP STUDIO FROM ANY AND ALL CLAIMS OF NEGLIGENCE, DAMAGES, OR LEGAL ACTIONS ARISING FROM OR CONNECTED IN ANY WAY TO MY TATTOO, THE PROCEDURE, AND CONDUCT USED IN MY TATTOO AND ASSUME ALL RESPONSIBILITY FOR THE DECISION(S) MADE CONSENTING TO THIS PERMANENT PROCEDURE.

I AM AWARE THAT TATTOOS, INK, 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.

ALL INFORMATION GATHERED FROM THE CLIENT IS PERSONAL MEDICAL INFORMATION, SUBJECT TO THE FEDERAL HEALTH INSURANCE PORTABILITY, AND ACCOUNTABILITY ACT OF 1996 (HIPAA) OR SIMILAR STATE LAWS SHALL BE MAINTAINED OR DISPOSED OF IN COMPLIANCE WITH THOSE PROVISIONS.

 

 

 

HEALED RESULTS WILL VARY FROM PERSON TO PERSON, AND USING A POWDER OR PENCIL MAY STILL BE NEEDED IN SOME CASES. BECAUSE WE HAVE NO CONTROL OVER WHAT OCCURS DURING THE HEALING PROCESS, ABSOLUTELY NO GUARANTEE WILL BE MADE, AND ADDITIONAL SESSIONS MAY BE REQUIRED TO OBTAIN OPTIMAL HEALED RESULTS. ADDITIONAL CHARGES WILL APPLY IN THESE CASES. ALTHOUGH WE GIVE OUR BEST EFFORTS TO PROVIDE YOU WITH THE HIGHEST QUALITY OF SERVICE, MANY FACTORS CAN RESULT IN A LESS-THAN-DESIRED OUTCOME DUE TO HEALING, SKIN TYPE, AND AFTERCARE.

SCHEDULING POLICIES

WE REQUIRE 72 BUSINESS HOURS NOTICE FOR CANCELING APPOINTMENTS. WE ASK THIS SO WE MAY OPEN UP YOUR TIME SLOT TO ANOTHER CLIENT. CANCELLATIONS MADE LESS THAN 72 BUSINESS HOURS MAY RESULT IN A CHARGE FOR THE SCHEDULED APPOINTMENT. NO-SHOW APPOINTMENTS WILL BE CHARGED $150. YOUR SCHEDULED APPOINTMENT IS BOOKED FOR YOU AND ONLY YOU, AND OUR ARTISTS CAN NOT FILL NO-SHOW APPOINTMENTS, SO WE ASK OUR CLIENTS TO HAVE CONSIDERATION FOR THEIR ARTISTS. WHEN SCHEDULING YOUR APPOINTMENT, WE REQUIRE A CREDIT CARD NUMBER TO HOLD YOUR APPOINTMENT. 

REQUIRED CONFIRMATIONS

APPOINTMENTS MUST BE CONFIRMED, AND WE'VE MADE IT SUPER EASY TO DO SO! EACH CLIENT RECEIVES A CONFIRMATION EMAIL 72 HOURS BEFORE THEIR SCHEDULED VISIT. THIS EMAIL HAS A BIG GREEN BUTTON TO CLICK THAT SAYS "CONFIRM. " TEXTS ARE ALSO SENT IF YOU ARE SIGNED UP FOR THEM; SIMPLY REPLY "YES. " IF THESE GO UNCONFIRMED, WE WILL CALL YOU FOR A CONFIRMATION DAY BEFORE.


 

CONSENT FORM CONFIRMATION

I HAVE COMPLETED THIS FORM TO THE BEST OF MY KNOWLEDGE AND AGREE THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND ACCURATE. BROWHOUSE IS NOT RESPONSIBLE FOR ANY SIDE EFFECTS CAUSED BY INACCURATE INFORMATION I HAVE DISCLOSED ON THIS FORM. I UNDERSTAND THAT WHILE EVERY PRECAUTION IS TAKEN, ADVERSE REACTIONS ARE A POSSIBILITY WHEN RECEIVING MY SERVICE, INCLUDING SKIN IRRITATION, LIFTING ETC. I UNDERSTAND ANY CONTRAINDICATION BOXES I CHECKED ON THIS FORM CAN INCREASE MY CHANCES OF ADVERSE REACTIONS TO SERVICES. I UNDERSTAND ALL HEALTH HISTORY INFORMATION I PROVIDED IS CONFIDENTIAL AND CAN NOT BE SHARED WITH ANYONE OTHER THAN BROWHOUSE AND ITS EMPLOYEES. I GIVE BROWHOUSE AND ITS ARTISTS PERMISSION TO PERFORM THE SERVICES I REQUEST.

THANK YOU FOR CHOOSING BROWHOUSE!

browhouse6464.jpg
bottom of page