Powder Ombre Brows / MicroShading Consent Form Name : * First Name Last Name Guardian's Name : (in case when the client is a minor) First Name Last Name Phone : * (###) ### #### Email : I hereby, agree to have Powder Ombre Brows procedure performed on my eyebrows. By signing this agreement, I consent to the Powder Ombre Brows procedure by a Brows on Fleek technician. I understand that on rare occasions there are risks associated with having Powder Ombre Brows procedure such as pigment migrating under the skin, and/or immediate or delayed allergic reaction to pigment. I further understand that a negative patch test result does not guarantee that an allergic reaction won’t develop after the full procedure, that allergic reactions to anesthetic may occur. It has been explained to me that Permanent cosmetics cannot be performed during pregnancy, nursing and on anyone under the age of 18. I understand that in rare cases as part of the procedure skin irritation and discomfort could occur as a result of the use of the instruments, chemical solution, tapes, cleaners, eye gel pads, adhesives and/or removers. I agree that if I experience any of these conditions with my skin and/or eyes that I will contact the certified technician that performed this procedure and that it may be beneficial to contact emergency medical services without delay, at my own expense. I understand and agree to the after-care instructions provided by the certified technician for the use and care of my eyebrows. I realize and accept the consequences of failure to adhere to these instructions may pull off scabs prematurely and cause patchy results or scarring. I am informing the certified technician of the following conditions/ contraindications by marking with a check, agreeing to have the procedure be performed on me despite any risk: Cancer and/or Chemotherapy or Radiation Glaucoma Hormone Imbalance Arthritis Fever Blisters Immune Disorders Blood Clots Migraines Systemic Disease Thyroid Condition HIV/AIDS Asthma Hepatitis Lupus Insomnia Skin Disease Spinal Injury Hysterectomy Eczema Herpes Metal Implants Seizure Disorder Active Infection Trichotillomania Diabetes Varicose Veins Epilepsy Cold Sores High Blood Pressure Heart Problems Phlebitis Keloid Scarring Alopecia I am informing the certified technician of the following conditions by marking with a check: • Current use of anything such as oil-containing sunscreen or moisturizer around the eyes. • Current use of any kind of prescription or over the counter. • Any history of Hyper-pigmentation and/or Hypopigmentation or marks after physical trauma. • Use of blood thinning medication. • Other medical conditions which would prohibit or compromise application of chemical dye. • Others (please specify): Allergic Reaction to any of the following: Lidocaine Tattoo Pigments Epinephrine Lecithin Latex Vaseline Dermacaine Propylene Glycol Hair Dyes Metals Benzyl Alcohol Vitamin E Acetate Glycerin Tetracaine Carbopol Others (please specify): Retin-A Glycolic Acid Tazorac Differin Renova AHA RoAccutane Accutane Adapalene Retinol Scrubs or Peels This agreement will remain in effect for this procedure and all future follow-ups conducted by the certified technician, and will hold the technician/s harmless from any liability that may result from this procedure. I read English and understand that this consent agreement is legal and binding. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above agreement clauses, and that I have had sufficient opportunity for discussion to have all my questions answered. I understand the procedure and accept the risks. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. I further agree that I will not hold Brows on Fleek or its affiliates or any of its employees responsible should there be any unfavorable outcome or result. Date : * MM DD YYYY Thank you!
