First Name

Last Name

Phone *

Email *

By checking this box, I consent to receive non-marketing text messages from LaBrows Beauty Studio about appointments, reminders and inquiries. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from LaBrows Beauty Studio at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Date of birth *

Address

Street Address

City

State

Postal Code

Are You 18 or Older? *

Yes

Have You Ever Received Any Type of Hair Color Service (Hair Dye)? *

Yes

Have You Ever Had an Allergic or Negative Reaction to Any Type of Hair Color Service? *

Yes

Have You Ever Received Any Type of Tattoo or Body Piercing? *

Yes

Have You Ever Had an Allergic or Negative Reaction to Any Tattoo or Body Piercing? *

Yes

Do You Have Keloid Skin? *

Yes

Are You Currently Under Any Doctor's Care? *

Yes

In the Past Two Weeks, Have You Had Botox/Dysport in the Forehead Region? *

Yes

In the Past Two Weeks, Have You Used Retin-A or Retinoid Products? *

Yes

In the Past Two Weeks, Have You Used Hyaluronic Acid? *

Yes

Are You Pregnant or Nursing? *

Yes

Are You Using Any Products or Medications That Could Affect Healing? *

Yes

Have You Recently Had a Skin Peel? *

Yes

Health Statement (Please Choose One) *

I have informed LaBrows Beauty Studio, LLC that I am in good health and not under the care of any physician.

I am currently under the care of a physician and being treated, and I have discussed this with LaBrows Beauty Studio, LLC technicians (conditions listed below).

List All Medications You Are Currently Taking (Including Retin-A, Glycolic Acid and Accutane) *

List Any Drug, Makeup, Skin or Food Allergies (i.e., Soaps or Cleansing Creams) *

What Products Do You Use for Skin Care? *

If Under a Physician's Care, List the Condition(s) Being Treated *

Physician's Name, Phone Number and Address *

Date of Your Last Eye Exam and Examining Physician *

Emergency Contact Name, Phone Number and Relationship *

How Did You Hear About Us?

Areas of Concern

Cancer Type or Other Health Details (If Any)

Medical History Certification and Release *

I certify that this Confidential Medical History Form was completed by me and all information is true and complete to the best of my knowledge. I also certify that I have been fully informed of the potential risks of tattooing/permanent makeup application, including but not limited to: infection, scarring, difficulties in detecting melanoma, and allergic reactions to permanent makeup/tattoo pigment, latex gloves, and any other products used. Having been informed of the potential risks associated with undergoing the permanent makeup/tattoo application, I still wish to proceed with the application and I assume all risks that may arise from the procedure. I also certify that I take full responsibility and waive any claims against LaBrows Beauty Studio, LLC to the fullest extent permitted by law from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise. This includes direct and/or consequential damages, which result or arise from the application and/or implantation of permanent makeup pigment for eyeliner, eyebrows, lips, re-coloration, or camouflage; whether caused by the negligence or fault of either LaJoy Grant or an associate of LaBrows Beauty Studio, LLC. I fully understand the questions, terms, and conditions of this Informed Consent, Medical History and Release Agreement, and all questions have been thoroughly answered for me.

Pre-Treatment Advice and Procedures

Please bring a valid government ID/driver's license to your appointment (required by law).
Since delicate skin or sensitive areas may swell slightly or redden, it is advised not to make social plans for the same day. Lip liner may appear "crusty" for up to one week.
Please wear your normal makeup to the procedure. If you are having lips or brows done, please bring your favorite pencils.
If unwanted hair is normally removed in the area to be treated (i.e., tweezing or waxing), hair removal should be done at least 24 hours before your procedure. Electrolysis should not be done within five days of the procedure. Do not resume any method of hair removal for a week after the procedure.
If eyelashes or eyebrows are normally dyed, do not have that done within 48 hours of this procedure. Wait one week after the eyebrow or eyeliner procedure before dyeing lashes or brows.
If you wear contact lenses and are having eyeliner done, do not wear your lenses to your appointment and do not replace them until the day after the procedure.
If you are having the eyeliner procedure done, as a safety precaution in case of watering or swelling, we recommend that you have someone available, or accompany you, who could drive you home if you so decide or if it is necessary.
If you are having lip liner done and have had previous problems with cold sores, fever blisters, or mouth ulcers, the procedure is likely to reactivate the problem. Your Intradermal Cosmetic Technician can make recommendations to help prevent or minimize the outbreak.
We recommend allergy testing of pigment before the planned procedure.
Do not use aspirin or ibuprofen, drink alcohol or work out for 24-48 hours before your procedure.

We look forward to working with you! If you have any questions, please call (214) 210-1103 or email [email protected], and/or make notes so we can discuss them with you when you arrive for your appointment. We look forward to you becoming a "LaBrows Beauty."

Pre-Treatment Acknowledgment *

I have read, understood, and agree that I have followed the Pre-Treatment Advice and Procedures above.

Disclosure and Consent for Tattoo and Dermal Procedures *

I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have had sufficient opportunity for discussion to have any questions answered. I understand that should I decide to forgo the procedure, all appointment retainer fees and/or deposits are non-refundable. I have requested that LaBrows Beauty Studio, LLC describe the procedure to be performed so that I may make an informed decision whether or not to undergo the procedure. LaBrows Beauty Studio, LLC has described the recommended procedure as Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin, a form of tattooing used for permanent cosmetic makeup and skin/structural imperfection camouflage. I voluntarily request the services of LaBrows Beauty Studio, LLC to perform intradermal cosmetics, along with any associations and technical assistance as they may deem necessary, for the procedure(s) I selected on this form.

Photo and Video Release *

I hereby authorize LaBrows Beauty Studio, LLC to take photographs or video of the work performed both before and after treatment, and I further authorize the use of said photographs or video for advertising, for training purposes, and to keep on file as professional records.

Pregnancy and Breastfeeding *

I confirm that I am not pregnant or breastfeeding. I understand that knowingly or unknowingly falsifying this information can be harmful to me or my unborn child and I am solely and fully responsible. I release LaBrows Beauty Studio, LLC and all staff from legal action and responsibility.

Semi-Permanent Makeup Is Tattooing *

I understand that semi-permanent makeup is a form of tattooing and requires implantation of pigments into my skin using a needle.

Discomfort and Pain *

I understand there is a possibility of discomfort and pain during this procedure.

Fading and Touch-Ups *

I understand this type of tattooing is considered semi-permanent: it will fade with time and therefore requires touch-ups. Results can vary and are dependent on the client's care and skin type. No guarantee has been made on tattoo longevity.

Color Loss During Healing *

I have been informed that I may lose significant areas of color during my healing process and I understand it can take 10-15 days for color to appear back fully. If the color does not return within that time frame, I should return for a touch-up within 6-8 weeks after the procedure to achieve the best results.

Skin Type and Results *

I have been informed that my results depend on my natural skin regeneration and/or skin type. Often, even with proper care, clients can develop light spots or lose original hair strokes, which can make the brow look uneven. This is absolutely normal because of natural skin regeneration and is not a process LaBrows Beauty Studio, LLC or any eyebrow technician can control. Skin type, excessively oily skin, larger pores, and thicker skin can affect the absorption of pigment. In this case one or more touch-ups will be needed to achieve optimum results.

Risks and Hazards *

I understand there may be risks and hazards related to the performance of this procedure, including but not limited to: allergic reaction to the pigment and/or other products that will be used, lightheadedness, bleeding, bruising, swelling, scarring and infection.

Responsibility to Notify *

I understand that it is my responsibility to notify LaBrows Beauty Studio, LLC of any problems that I (or my doctor) think could occur for any reason (including but not limited to: allergies, illnesses, medications, including aspirin and/or other medications that cause the blood to thin). I understand that LaBrows Beauty Studio, LLC may elect to delay or not go forward with the procedure based on this information.

Cancellations and Conditions *

I understand that if I cancel my appointment, or LaBrows Beauty Studio, LLC finds that I have any condition that would interfere with performing the service, the pre-scheduled appointment will be automatically canceled and I must pay the full balance of the allotted time.

No Warranty or Guarantee *

No warranty or guarantee has been made to me as a result of this permanent makeup/camouflage/correction procedure, and although LaBrows Beauty Studio, LLC will do their best to make sure I am happy with the results, the final result cannot be guaranteed.

Symmetry *

I understand that LaBrows Beauty Studio, LLC will do their best to ensure the most possible symmetry of my brows; however, there is no guarantee of symmetrical brows due to my natural physical features being asymmetrical.

Aftercare Instructions Received *

I have received a written copy of aftercare instructions for the tattooed area. All instructions have been explained to me in depth.

Complaints *

I understand that if I have any issues with my services at LaBrows Beauty Studio, LLC, I will forward my complaints solely to the management department via email: [email protected].

Procedure Clarification: Pain and Discomfort *

I have been told that this procedure may involve pain and/or discomfort during or shortly after the procedure.

Permanent Markings and Hyperpigmentation *

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

Follow-Up Procedure *

I have been told that a follow-up procedure may be required.

Other Risks *

Other risks involved with the procedure may include, but are not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction(s) to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.

Medical Treatment Responsibility *

I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me.

Opportunity to Ask Questions *

I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved, and I believe that I have sufficient information to give this informed consent.

Complaints and Arbitration *

I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify LaJoy Grant, 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 LaJoy Grant 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 judgment of the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

Reporting Reactions *

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify LaBrows Beauty Studio, LLC, a health care practitioner, and the Texas Department of Health, Drugs and Medical Devices Division.

Form Fully Explained *

I certify this form has been fully explained to me and I have read it or it has been read to me. I understand its contents.

Post-Procedure Instructions *

I have received a copy of the Post-Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its contents.

Spot Testing: Purpose of This Description *

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure.

Known and Unknown Risks *

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

Manufacturer Spot Testing *

I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment.

Right to Waive the Color Test *

I also understand that I have a right to waive the color test, and by doing so, I cannot hold LaBrows Beauty Studio, LLC or the manufacturer of pigments used liable for any adverse reaction to color pigments.

Delayed Allergic Reactions *

I understand that spot testing does not identify individuals who may have a delayed allergic reaction to pigment.

Spot Test Release *

Whether I receive or waive a spot test, I agree to release LaBrows Beauty Studio, LLC, their technicians, trainees, assistants and pigment manufacturer(s) from any/all liability related to allergic reaction or any other reaction to applied pigments.

Spot Test: I Agree to Receive or Waive a Spot Test Prior to Application *

Receive a spot test

Waive the spot test

Aftercare Instructions

For eyebrows, eyeliner, lip liner/full lips, areola and scar camouflage.

Immediately following your procedure: Apply ice to the treated area for 10-30 minutes. Ice helps reduce swelling and aids in healing.

For 14 days following your procedure:

Apply grapeseed oil sparingly twice a day beginning 2-3 days after your procedure, using a clean cotton swab, not your fingertips.
Do not rub or pick at the crust; allow it to flake off on its own. No scrubbing, cleansing creams or chemicals. Gently cleanse the area with a mild antibacterial soap, rinse with water and lightly pat dry. Do not expose the treated area to the full pressure of the shower.
Do not soak the treated area in a bath, swimming pool or hot tub. Do not swim in fresh, salt or chlorinated water.
Do not expose the treated area to the sun.
Use a total sun block after the area has healed to prevent future fading of pigment color.
Do not use mascara or an eyelash curler for seven days after the procedure. When you resume, purchase a new tube; the old tube may have bacteria in it.
If you are a blood donor, you cannot give blood for 1 year following your procedure (per the American Red Cross).

At the first sign of an infection, adverse reaction or allergic reaction, notify LaBrows Beauty Studio, LLC, a health care practitioner, and the Texas Department of Health, Drugs and Medical Devices Division (512) 834-6755.

Failure to follow post-treatment instructions may cause loss of pigment, discoloration or infection. Colors appear brighter and more sharply defined immediately after the procedure; as healing progresses, color will soften. A touch-up may or may not be necessary. Final results cannot be determined until healing is complete. Touch-ups must be made between 30-60 days following the procedure; additional fees apply for touch-ups after 60 days.

Questions? Call or text (214) 210-1103. Thank you for the gift of your business. Enjoy your cosmetic services!

Client Signature (I have read and agree to this entire consent form) *

Clear