BROW SUGA BEAUTY BAR

Disclosure and Consent for Intradermal Cosmetic Procedures: Specifically Microblading

Participant's Name

First Name *

Last Name *

Phone *

Participant's Date of Birth

Date of birth *

I certify that I am 18 years of age or older

I have requested information relating to the procedure of intradermal Cosmetics so that I may make an informed decision as to whether or not to undergo the procedure. The type of intradermal cosmetic procedure used will be Micro Pigment Implantation, the process of implanting micro pockets of pigment into the dermal layer of the skin. This is a form of tattooing used for permanent and semi-permanent cosmetics and camouflaging skin imperfections such as scars and stretch marks. I voluntarily request as my intradermal cosmetic technician Tawana Deas and such association and technical assistance as she/he may deem necessary to perform on my body the following procedure(s). MICROBLADING *

I hereby authorize photographs of the work performed to be taken both before and after treatment for my client's records. *

I hereby authorize photographs of the work performed to be taken both before and after treatment and that said photographs may be used for purposes of advertising and/or training. *

Please select the ONE that applies to you: *

I am in good health and NOT under the care of any physician.

I am currently under the care of a physician currently receiving. If yes, we would like to know whom so that we can coordinate your care.

Physician Name

Physician's Phone Number

Physician Address:

Participant's Information

Your Name: *

Address *

City *

State *

Zip code *

Procedure Requested: Microblading

What do you want to fix about your brows? *

What are some additional questions you have before we start this procedure? *

FOR OFFICE ONLY. Pigment(s) Used:

FOR OFFICE ONLY. Blades Used:

Please check to indicate if you have ever had the following conditions: *

HIV/AIDS

Hepatitis

Are you or could you be Pregnant? *

Yes

Would you like to receive topical numbing? If yes read and check the boxes below: *

I hereby authorize medical-grade numbing cream

I have no known or unknown allergies to Lidocaine, Benzocaine, or Tetra Caine

*We follow the HIPPA guidelines. HIPPA is the Federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative cost.

I have been told that there may be known or unknown risks and hazards related to the performance of the planned procedure and I understand that no warranty or guarantees have been made as to the results. *

I acknowledge the manufacturer of the pigments requires spot testing and specifically disclaims any responsibility for any adverse reaction to applies pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however, spot testing does not identify individuals who may have a delayed allergic reaction to pigment. *

I certify that I have read, this consent and fully explained and I understand its contents. *

I have read and received a copy of the Post Procedure Instructions and I understand its content. *

Client Signature *

Clear

Date: *

Representative Signature: *

Clear

For Permanent Makeup Intradermal Cosmetic Procedures:

We are so pleased to have you as a client and we look forward to providing you a wonderful service.

I understand that if I have an infection, adverse reaction, or allergic reaction to the procedure, I must notify a healthcare provider and the Texas Department of State Health Services at (512)834-6626.

I have read, the above post-procedure instructions and FULLY understand the information contained therein.

I agree to (circle one): Receive release Tawana Deas and its Representatives,

Waive a spot test prior to application and I agree to

Assistants, and pigment manufacture(s) from any and

all liability related to allergic reaction or any other reaction to applied pigments.

I have been told that this procedure may involve pain and discomfort.

I understand the markings are permanent and that there is the possibility of hyperpigmentation resulting from the procedure, especially in individuals prone to hyperpigmentation from scar or other injury.

I understand that a follow-up procedure may be required.

I understand other risk involved with the procedure may include, but are not limited to: infections, allergic and other reactions to applied pigments, allergic and other reactions to products applied during and after the procedure, fanning or spreading of pigments (pigment migration), fading or

color.

I accept FULL responsibility for any and all, present and future, medical treatments and expenses I may incur in the event I need to seek treatments for any known or unknown reason associated with this procedure.

I have been given the opportunity to ask questions about the procedure(s) to be performed/used and the risks and hazards involved, and I believe that I have sufficient information to give informed consent.

I agree that should I have a complaint of any kind whatsoever, I shall immediately notify Tawana Deas, and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and Tawana Deas or the breach thereof, shall be settled by Arbitration in the state of Texas in accordance with the Rules of the American Arbitration Association and judgement of the award rendered by the arbitrator(s) may be entered in any court that has jurisdiction.

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Tawana Deas, a healthcare provider and the Texas Department of State Health Services.