POWDERBROWS CONSENT FORM
MEDICAL HISTORY
PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING
In consideration of receiving BODY ART from Celina Hoang Yen Le, the practitioner at Celina Brows (together with its employees, apprentices, and agents, the “Body Art Business”)
Note: The FDA does not regulate the inks and colors used in permanent makeup procedures.
AFTERCARE INSTRUCTIONS
The following written instructions were communicated to the client:
1. Information on the care of the procedure site.
2. Restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with animals for 7 days
3. Be aware of infection signs, such as increased redness, swelling, tenderness at the procedure site, red streaks extending from the area, elevated body temperature. These symptoms require immediate medical attention.
4. Instructions to call a physician if any of the addressed signs and symptoms appear or for any other reason related to the Body Art procedure(s).
5. If physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body Art facility and practitioner of the problem and the resolution by a physician or clinic. This information shall be placed in the client’s file.
INSTRUMENT LOG (to be filled by artist/practitioner)
If single-use, pre-packaged, pre-sterilized instruments and needles are used please maintain the following records:
(1) A record of purchase and use of all single-use instruments.
(2) A log of all procedures, including the names of the practitioner and client and the date of the procedure.
(3) Written proof on company or laboratory letterhead showing that the presterilized instruments have undergone a sterilization process. Written proof shall
clearly identify the instruments sterilized by name or item number and shall identify the lot or batch number of the sterilizer run.
By providing my phone number, I agree to receive text messages from the business regarding aftercare instructions, appointment reminders, and promotions.