Kreem Pink Box - Consent and Release Agreement

This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery Semi-permanent make up application. If you have questions, please don‘t hesitate to ask. Although 3D Eyebrow Embroidery is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure. This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are strictly adhered to. Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed. Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7 days the color will fade 20 -30%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years.

Photography Release Consent

We would like your permission to use these photos for advertising. For example, in portfolios, online and in print ads, etc. Your consent is necessary regarding this. Please check and indicate with your signature if you would like your photos used or not used in advertising.

Yes, feel free to use them

No, please do not use them

Date

YYYY

Name

First Name

Last Name

Phone

(###)

###

####

Special requests, concerns, or remarks for technician:

Technician's name

Possible risks, hazards or complications

•Pain: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others. •Infection: Although rare, there is a risk of Infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care” sheet for instructions on care. •Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance. •Asymmetry: Every effort will be made to avoid asymmetry but our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness. •Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-5 days. Some people don’t bruise or swell at all. •Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now. •MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics. The alternative to these possibilities is to use cosmetics and not undergo the 3D Eyebrow Embroidery procedure.

Allergic Reaction

There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7 day patch test to determine this. Please check to

Waive allergy test

Take allergy test

STATEMENT OF CONSENT AND RECITALS: Please read and check all lines for understanding

instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions I will call or email you.

I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.

I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color.

I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.

I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI. accept the responsibility for explain to you my desire for specific colors, shape, and position for any procedure done today.

I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch up session within 60 days.

I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.

I have been quoted the cost of today’s appointment which includes one (1) touch up after 30 days and within 60 days. After 60 days a fee will apply and there will be no refunds for this elective procedure(s).

I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize a trained Real Eyez Beauty technician or a Real Brows student in training, as my Eyebrow Embroidery technician to perform on my body the 3D Eyebrow Embroidery procedure desired today.

Client Medical History

Birthday

YYYY

Driver License or ID Number

Address

Emergency Contact Name

Emergency Contact Phone Number

(###)

###

####

How did you hear about us?

Year?

Accutane or acne treatment

Chemotherapy/ Radiation No Tan by booth or sun

Tumors/ Growths/ Cysts

Difficulty numbing with dental work

Taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin, ect.

Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect.

If you have allergies, explain what you are allergic to.

I agree that all the above information is true and accurate to the best of my knowledge.

Name

First Name

Last Name

Date

YYYY

EYEBROW AFTERCARE

Careful aftercare is very important for producing a beautiful and lasting result. ● It’s important not to get the brows wet during the healing process (10 days). ● Use clear triple antibiotic ointment for 24 hours, then switch to Vaseline, Auqaphor or A&D for the remaining 9 days. When applying ointments, the following procedure is done each morning and night or before a shower or workout for the full 10 days: Apply the product, leave it on for five to ten minutes (or while in shower), then with a tissue or dry cotton wipe gently across each brow once to get off the excess goo, then dab each brow till it is dry, after a couple minutes dab again to ensure that nothing is left on the brow. However, starting on day three when scab starts to appear, do not wipe - only dab till dry, you must be gentle, do not pull off the scabs prematurely. Your brows should remain dry all day and all night. Following this procedure will ensure the formation of thin scabs thus more color retention. Keep out of the sun for seven days. Then after seven days wear sunscreen to aid in the longevity of your tattoo. ● As instructed apply the ointments with freshly washed hands or a Q-tip. Never touch the procedure area without washing your hands immediately before. It is very important to keep the brows covered with ointment while in shower or during a strenuous workout to prevent moisture from penetrating. Remove ointment per above instructions. ● Do not scrub, rub or pick at the epithelial crust that forms. Allow it to flake off by itself. If it is removed before it is ready the pigment underneath it can be pulled out. ● Do not use any makeup on the brows for at least 5 days. ● After the procedure is completely healed, you make go back to your regular cleansing and makeup routine. Avoid scrubbing the area. Use sun block after the procedure area is healed to protect from sun fading. ● FAILURE TO FOLLOW AFTER-CARE INSTRUCTIONS MAY RESULT IN INFECTIONS, PIGMENT LOSS OR DISCOLORATION. Cautions: If the skin around the eyebrows breaks out in a heat rash, small pimples, this is usually a reaction to the numbing solution and should go away by itself in a couple weeks, don’t pick. Please call immediately if this occurs so a technician can make note of the reaction and follow up to ensure this is not a more serious situation. Warnings ▪ Do Not use any Retin-A or Glycolic Acids in the brow area during or after healing! ▪ Do Not scrub or pick treated areas! ▪ Do Not expose area to the sun or tanning beds! ▪ Avoid swimming pool for 14 days! ▪ Do Not dye or tweeze eyebrows for one week after the procedure! ▪ Failure to follow post procedure instructions may result in infection or loss/discoloration of pigment. What is normal? ● Mild swelling, itching, light scabbing, light bruising and dry tightness. Ice packs are nice relief for swelling and bruising. Aftercare ointments work well for scabbing and tightness. ● Too dark and slightly uneven appearance. After 2-7 days the darkness will fade, and once any swelling dissipates unevenness usually disappears. If it is too dark or still a bit uneven after 4 weeks then we will make adjustments during the touch up appointment. ● Color change or color loss. As the procedure area heals, the color will lighten and sometimes seem to disappear in places. This can all be addressed during the touch up appointment which is why touch up is necessary. The procedure area has to heal completely before we can address any concerns. Healing takes about four weeks. ● Need a touch up months later. A touch up may be needed 6 months to 1 year after the first touch up procedure depending on your skin, medications, and sun exposure. We recommend the first touch up 30 days after the first session; which is included in today’s price. Then every 6 months to 1 year to keep them looking fresh and beautiful. Future touch up sessions will cost the current touch up rate at the time you have it done. If most of the hair strokes have faded, the entire procedure will need to be repeated. An email photo “°consultation may be necessary to determine if you need a touch up or a repeat of the entire procedure. The client shall consult a health care practitioner at the first sign of infection or an allergic reaction, and report any diagnosed infection, allergic reaction, or adverse reaction resulting from the tattoo to the artist and to the TDSH Services, Drugs and Medical Devises Group at 1-888-839-6676

I have read, understand, and agree to the above aftercare instructions.

Name

First Name

Last Name

Date

YYYY

Eyebrow-Waiver

waiver must be completed prior to your microblading appointment.