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SEMI-PERMANENT MAKEUP CONSENT FORM

Please Read and initial / sign all lines

The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complication during and following its performance. I understand that may be certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly care for, but may occasionally occur.

By signing/initialing bellow, I specifically acknowledge that I have been advise of the facts and matter set below, and I agree as follows:

I am over the age of 18 and desire to receive the indicated semi-permanent makeup (cosmetic tattoo) procedure. The general nature of cosmetic tattooing as well the specific procedure to be performed has been explained to me.


April 24, 2024

I have been informed of the nature, risks and possible complications and consequences of semi-permanent makeup (cosmetic tattoo) skin pigmentation, I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning, or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin, I fully understand this is a semi-permanent makeup (cosmetic tattoo) process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure (s) and accept the permanence of the procedure as well as the possible complications and consequences of that said procedure (s)


April 24, 2024

I understand that may be a certain amount of discomfort of pain associated with the procedure and that other adverse side effect may include minor or temporary bleeding, bruising, redness or other discoloration and swelling. Secondary infection in the area of the procedure may occur, however if proper cared for, is rare.


April 24, 2024

I consent to the taking of before, during and after photographs & videos give permission to use such photographs for publications and/or for teaching purpose, as they choose.


April 24, 2024

I understand that if I have any skin treatments, laser treatments, laser hair removal, injections, plastic surgery or any 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 further understand that such changes are not the responsibility of my permanent makeup artist.


April 24, 2024

I understand that sun, tanning beds, pools, some skin care products and medication can affect my semi-permanent makeup (cosmetic tattoo).


April 24, 2024

I accept the responsibility to explain fully to you my desire for specific color shape, and position for any procedure done.


April 24, 2024

I understand that implanted pigment color can slightly change or fade over time to circumstances beyond your control and I will need to maintain the color with future applications and touch up sessions.


April 24, 2024

I understand and acknowledge that I must approve the mapping and color choice of my permanent cosmetic tattoo, which will be draw to my specifications prior to the procedure by Adriana Rebis.

I have received pre-procedural instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood-altering prescription, I will advise permanent makeup artist. 


April 24, 2024

I acknowledge and agree that I will be give aftercare instructions for the procedure I undergo, and I will follow the instructions to the best of my ability. If I have questions I will text, call or email you.


April 24, 2024

POSSIBLE RISK, HAZZARDS, OR COMPLICATIONS

*Asymmetry: Every effort will be made to avoid asymmetry, but our faces are not symmetrical, so adjustments may need during the follow-up session to correct any unevenness.

*Uneven Pigmentation: This can result from poor healing, infection, bleeding, or may other cause. Your follow up appointment will likely correct any uneven appearance.

*Infection: Infection is very unusual. The area treated must be kept clean and only freshly cleaned hands should touch the area. See aftercare" sheet for instructions on care.

*Anesthesia: Topical anesthetic are used to numb the area to de tattoo. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and Epinephrine in a cream or gel form are typically used. if you are allergic to any of these please let me know.

*PAIN: there can be a slightly small pain even after the topical anesthetic has been used. Anesthetics works better on some people than others.


April 24, 2024

Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the company and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.


April 24, 2024

I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.


April 24, 2024






First Client's Name

First Name*

Last Name*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Medical History Screen, Check all that apply*
Are you allergic to penicillin or any other drug?
Auto-immune disorders
Blood deficiencies such HIV / Hepatitis
Pregnant/ Breastfeeding
Oily Skin
Epilepsy
Going through or have had chemotherapy
Pacemaker or major heart problems
Illness: cold, flu, covid, etc.
Uncontrolled diabetes
Uncontrolled high blood pressure
Used Accutane in withing the past 6 months
Allergies to any medication or latex
Allergic to Novocain, Lidocaine or any topical anesthetics
Bleeding disorders
Taking recreational drugs
Skin conditions in the brow area: eczema, rashes, keloides

Are you presently taking any medication? List:
Do you agree to the fees discussed?*
No
Yes

I fully understand that a deposit of a $75 is required to schedule an appointment, in the event of cancellation of procedure with less than 72 hour notice, the deposit becomes non-refundable.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. Subsequent visits are subject to $120/$200 charge depending upon the amount of work needed.

There is a small possibility of an allergic reaction. A patch test can be done to ensure you don't have an allergic reaction. pigments.

Patch test: (You MUST make a separate appointment if you would like a patch test and wait 3 weeks for results)*



If waived, I release the technician and assistants from liability if I develop an allergic reaction to the pigment. (Pigments contents are: iron oxide, lakes, alcohol, Glycerin and distilled. Sterile water)

I acknowledge that NO GUARANTEES have been made to me concerning the results of this procedure. For the purpose of documentation, I also consent to the technician, salon or clinic.

I have read the above and had explained to me and fully understand this consent and procedure form: that the explanations therein referred to, were made, and I accept full responsibility for these or any other complications which may arise from results during or following that cosmetic procedure which is to be performed at my request according to this consent and procedure form.


Please select all that apply: I request permanent cosmetic make-up procedures
Microblading
Eyelash Enhancement
Have you ever had any permanent cosmetics applied? If, Yes I understand that correcting or touching up micropigmentation/microblading that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Adriana Rebis has no control.*
No
Yes

If so please describe

I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedures(s) which is to be performed at my request according to this consent were filled in before I signed this statement.

Phi' Brows U24 Blade, Lot# 8606019518523, Exp, 07/07/2023

Phi' Brows Pigment Brown 1, Lot# BB200001, Exp, 09/2023

Phi' Brows Pigment Brown 2, Lot# BB21001, Exp, 06/2024

Phi' Brows Pigment Brown 3, Lot# BB20003, Exp, 09/2023


Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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