Disclosure & Release Form for Implantation of Pigment

Bella Brows & Spa appreciates your patronage and interest in new and improved techniques of semi permanent makeup.

You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is not meant to frighten you. It is simply an effort to make you better informed so you may give or not give your consent to the procedure.

CLIENT INFORMATION

We will never disclose or share your personal information with a 3rd party or any other purpose. Your information is captured so that we may contact you when it is time to do your touchups and/or when we have any upcoming promotions.

First name

Last name

Date of birth

Phone Number

E-mail Address

Appointment Date

What is your appointment for:

How were you referred to our facility:

CLIENT DISCLOSURE

Please read the statement below, checking each box to indicate your agreement.

I understand the following completely:

I acknowledge that no warranty or guarantee has been made to me as a result of this permanent makeup/ camouflag/ correction procedure, and that the final result cannot be guaranteed.

I realize that there is potential for discomfort during the procedure and during the healing process as well as possibility of bleeding, swelling and allergic reactions to the dye.

I acknowledge that the tattooing is considered permanent, however, it will fade with time.

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.

I have received post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful result.

I understand that the healing process is different for every person. Pigment loss or color change normally happens in most of the cases during the first week. I have to stay calm, not panic and return for a touchup session no earlier than 4-6 weeks after the initial session (when skin is completely healed).

I have been given the opportunity to ask questions about the procedure, the risks and the hazards involved.

I believe that I have sufficient information to give the informed consent.

CLIENT ACKNOWLEDGEMENT AND RESPONSIBILITY TO INFORM THE TECHNICIAN

CLIENT further agrees to indemnify and hold harmless Bella Brows & Spa, its governing officers, consultants, employees, agents, and subsidiaries, from any claims of liability, losses, damages, or any expenses whatsoever as a result of any claims, demands, damages, costs or judgment including, but not limited to, claims based on negligence against it, that may arise in connection with the services performed by an independently contracted technician.

This Agreement is intended to be an addendum to any previous conditions, releases, or hold harmless agreements, in written form, verbal, or manually communicated between Bella Brows & Spa and its client in connection with permanent makeup procedures.

As a client, you have a responsibility to inform the Technician of all possible concerns. Please read the following and initial before each statement.

I understand that I must inform my technician of all medications being taken by me, even though I have written it on the medical history. For eg. Pain control medication such as aspirin may cause the blood to thin, and excessive bleeding may occur.

I understand that it is my responsibility to advise the technician of any concerns I may have before they begin the procedure, even though I may have written it down on the form.

I am over the age of 18 and I am free from drug and alcohol use or any other substances.

I am not pregnant.

I have no known allergies to dye, nickel, any topical anesthetics.

I understand that taking Before and After pictures is a condition of such procedures. I hereby forever release and discharge Bella Brows & Spa from any and all claims, action and demands arising out of use of said photographs for website, social media and online use.

I have also read and understand Aftercare Treatment Instructions and recommendations and I understand my responsibility to follow them to ensure proper healing of the treated area.

I release Bella Brows & Spa and its representatives and subsidiaries of all claims for injury, seen or unseen that may occur as a result of this procedure.

MEDICAL HISTORY

Allergies to any medications or foods:

Current medications:

Previous surgeries:

If you checked any of the above, when and which area:

I fully understand the questions, terms, and conditions of this Disclosure and Release Agreement, and all have been explained to me in my native language. I accept to waive all my rights for any claim against the technician/Bella Brows & Spa for any reasons may involve whatsoever. I certify that this Disclosure and Release Agreement was completed by me and that all entries in it and information are true and complete to the best of my knowledge.

I acknowledge that all the above information in the Medical History section was filled out by me and is true and accurate to the best of my knowledge.

Client's Printed Name

Client's Signature

Date Signed

Disclosure & Release Form for Implantation of Pigment

CLIENT INFORMATION

CLIENT DISCLOSURE

CLIENT ACKNOWLEDGEMENT AND RESPONSIBILITY TO INFORM THE TECHNICIAN

MEDICAL HISTORY

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