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CONSENT FORM

BROWHOUSE CONSENT FORM
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SERVICE PRECAUTIONS 

PLEASE READ CAREFULLY 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 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.

ALLERGIC REACTION: CAN OCCUR FROM ANY ANESTHETICS USING DURING 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 PAST WEEK FOR REGULAR BOTOX CLIENTS. (BROWS) 

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

I HAVE NOT USED RETINOL AND/OR RETIN-A IN THE PAST TWO WEEKS. (BROWS)

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



 

HEALTH QUESTIONNARE

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I ACKNOWLEDGE THAT OBTAINING PERMANENT MAKE UP IS MY CHOICE ALONE AND THE APPLICATION OF PERMANENT MAKE UP 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 MAKE UP 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 THINS 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 AND HAVE BEEN ADVISED OF ANY MEDICATIONS AND PROCEDURE 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 MAKE UP, OR ANY OPEN WOUNDS OR LESIONS AT THE SITE OF THE TATTOO.

I DO NOT HAVE A HISTORY OF MEDICATION USE OR CURRENTLY USING MEDICATION, INCLUDING BEING PRESCRIBED ANTIBIOTICS PRIOR TO DENTAL OR SURGICAL PROCEDURES. ANY AND ALL MEDICAL CONDITIONS REQUIRE PHYSICIAN APPROVAL FOR ANY SERVICE. IT IS THE CLIENTS RESPONSIBILITY TO OBTAIN THIS APPROVAL AND THE BROWHOUSE IS NOT RESPONSIBLE IF SAID CLIENT HAS NOT DONE THEIR RESEARCH AND/OR RECEIVED PHYSICIANS 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 MAKE UP PROCESS AND FURTHER ACKNOWLEDGE THAT SUCH REACTION IS POSSIBLE. 

I HAVE 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 MAKE-UP 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 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 THAT IS PERSONAL MEDICAL INFORMATION AND THAT IS SUBJECT TO THE FEDERAL HEALTH INSURANCE PORTABLITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) OR SIMILAR STATE LAWS SHALL BE MAINTAINED OR DISPOSED OF IN COMPLIANCE WITH THOSE PROVISIONS 

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 OF THE SCHEDULED APPOINTMENT. NO-SHOW APPOINTMENTS WILL BE CHARGED $150. YOUR SCHEDULED APPOINTMENT IS BOOKED FOR YOU AND ONLY YOU, OUR ARTISTS CANNOT FILL NO-SHOW APPOINTMENTS, SO WE ASK OUR CLIENTS TO HAVE CONSIDERATION FOR THEIR ARTIST. 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 HOUR 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 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 THAT ANY CONTRAINDICATION BOXES I CHECKED ON THIS FORM CAN INCREASE MY CHANCES OF ADVERSE REACTIONS TO SERVICES. I UNDERSTAND THAT ALL HEALTH HISTORY INFORMATION I HAVE PROVIDED IS CONFIDENTIAL AND CANNOT BE SHARED WITH ANYONE OTHER THAN BROWHOUSE AND THEIR EMPLOYEES. I GIVE BROWHOUSE AND THEIR ARTISTS PERMISSION TO PERFORM SERVICES I REQUEST.

THANK YOU FOR CHOOSING BROWHOUSE!

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