Waiver for Microblading process by BROWS BY MASHAE

Waiver

To expedite your service please fill out our waiver form.
Date

MonthDayYear
I am over the age of 18 and desire BROWS BY MASHAE's to perform the elective cosmetic pigmentation procedure understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantees have been made to me concerning the results of the procedure(s).

I also understand that the permanent skin pigmentation procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes the risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin.

For the purpose of documentation, I also consent to the taking of before, during and after photographs/videos of said procedure(s) which become the technician's sole property and may or may not be used for what ever purpose deemed necessary including using pictures for social media and advertising publications. IF YOU DO NOT WANT YOUR PICTURES POSTED ONLINE PLEASE ADVISE YOUR TECHNICIAN. Understanding the permanent skin pigmentation procedure, the procedure, the permanency of the procedure, the possible consequences of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize BROWS BY MASHAE to perform the permanent skin pigmentation procedure(s).

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 procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.
I certify that I am 18 years of age or older*

Confirm
Initial:*

Clear
Client's Full Name*

First NameMiddle NameLast Name
Email Address*
Client's Information
Check if you answer YES to any of these questions:

Are you allergic to penicillin or any other drug?Do you have any allergies to latex? powder in gloves?Do you take Zovirax, Valtrex or Famvir?Do you have any kind of heart trouble?Are you allergic to or ever had any reaction to Polysporin, Bacitracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?Are you allergic to novocaine or any caine anesthesia?Are you prone to, or have any keloid scars?Do you wear contact lenses, have implants or any eye problems?Are you taking recreational drugs?Have you had botox or any facial injection in the last 3 weeks?Do you have excessively oily skin?Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Are you presently taking any medications? If Any please provide the names seperated by commas:
Names Of Medicines
Are you allergic to any foods or medications? If Any please provide the names seperated by commas:
Names of Food or Medications
Are you presently under a physician's care? What for?
I fully understand that a cancellation fee of 50% of the price of the procedure will be
charged or deducted from the deposit in the event of cancellation of the procedure with less than 48-hour notice.

I absolutely understand that this procedure is a process and subsequent visits are necessary in order to achieve desired
results. If the Subsequent visits were not included in the package they will be subject to $100 charges depending upon the amount of work needed. There is a
possibility of an allergic retain of pigments. A patch test if advisable however it does not ensure a client will not have an
allergic reaction.

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, Glycerine
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. Laser treatments or ANY
kind of facial injections may also compromise your permanent cosmetic makeup application.

I will follow all 'After Care' instructions explicitly. Failing to do so will compromise my final results.
Medical Consent and Procedure Chart
If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure:

AspirinAntibioticsAccutaneSeizure medsMeds for mood changeAnticoagulantsDiabetic medsHeart medsTranquilizersSteroid preparationsBlood thinnersInsulin injectionsBlood pressure medsPain or headache medsArthritis PreparationsHormonesAnti-anxiety drugsMeds for depressionMeds for mood changeSteroid preparations
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure:

AnemiaSinus infectionsBlurred visionHeart diseaseHypertensionJaundiceAny breast problemsCollagen injectionsAsthmaChronic sinus congestionGlaucomaHeart conditionDiabetesHepatitisChronic skin problemsGortexFever BlistersSeasonal hay feverHistory of seizuresHeart murmurAlopeciaCancer surgeryDermabrasionAny other lip fillersHerpes infectionsChronic/ migraine headachesChronic eye conditionsRecurrent heart palpitationsElevated blood pressurePlastic surgeryChemical peelsNervous condition
Could you possibly be pregnant? WE CANNOT PERFORM ANY PROCEDURE ON PREGNANT WOMEN*

YesNo
Are you nursing mother? NO ANESTHESIA WILL BE APPLIED ON NURSING MOMS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.*

YesNo
Do you have any allergies to any medication or latex?*

YesNo
Novocain, Lidocain or any other topical anesthetics?*

YesNo
Have you ever had any permanent cosmetics applied in the past? A CONSULTATION IS REQUIRED PRIOR TO ANY PROCEDURES IF YOU HAVE EVER HAD PERMANENT MAKE UP DONE.*

YesNo
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 procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.
Signature*

Clear
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.Disagree
Please Agree before submitting the form
Should be Empty:

Waiver

Client's Information

Medical Consent and Procedure Chart

Electronic Signature Consent