Consent Form

Name:_____________________________

Date:_____________________________                



Phone:_____________________________             Email:_____________________________



How did you hear about Pashyra:


_______________________________________________________                




INFORMED CONSENT FOR PERMANENT COSMETIC ENHANCEMENT


My procedure(s) today is/are:  Check all that apply.

                

                               Ombre Powder Brows            Combo Brows              Microblading            


Please initial below:


    ______  I hereby authorize Pashyra, LLC to perform upon myself permanent cosmetic enhancement. If any unforeseen condition arises in the course of the procedure(s), I further request and authorize Pashyra -The Beauté Bar, LLC to use its full judgment and do whatever is deemed advisable and necessary in the circumstances without any liability to Pashyra -The Beauté Bar, LLC.


  ______  I understand that semi-permanent and permanent cosmetic enhancement is an advanced form of tattoo.


   ______ I accept full responsibility for determining the color, shape, and position of the enhancement as mutually agreed upon during the course of my consultation.


  ______ I understand that a commercially reasonable effort will be made to avoid unevenness, but some bone structure, facial deformity or birthmarks, or muscle movement does not call for perfect symmetry.


  ______ I was made aware that I am able to take an allergy test prior to procedure day and understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs.  


   ______ I understand that employee(s), practitioner, or any personnel from Pashyra, LLC are not licensed physicians or  

  medical doctors and was made aware to seek licensed physician or medical doctor’s opinion if needed.


    ______ I am aware that a sensitivity reaction to anesthetics can occur and accept all responsibility if allergic response occurs.


    ______ I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over the course of 1 to 3 years. Even though the color has faded, the pigment will stay in the skin indefinitely and may leave a light residue of color on the skin.


   ______ I understand that dyes, inks, and pigments are not approved by the Food and Drug Administration (“FDA”), and the health effects are not known.


 ______  I accept that the highest standards of hygiene are met, and that sterile disposable needles are used for each individual client, procedure, and visit.  


   ______  I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I may need to return for a touch up procedure or additional touch-ups thereafter.


  ______ I understand that the touchup procedure, if required, will be performed 4 to 8 weeks after the initial procedure, and that after the 8 week period, I will be charged an additional fee for any procedures or services. I will book the appointment when it is convenient for both parties.


 ______ I understand that all services are non-transferrable and non-refundable (full or partial refund).


 ______ I understand that semi-permanent cosmetic enhancement is an invasive procedure, and the infusion process can be uncomfortable or sometimes painful depending on my sensitivity.


 ______  I am aware that the result of the procedure is determined by the following:


Medication                                                                          

A compromised immune system

Skin Characteristics -  i.e. dry/oily/sun-damage                  Poor Diet

Natural skin undertones                                                      Post procedure care treatment

Alcohol intake and smoking                                                Lifestyle

General stress                                                                     Sun Exposure


  ______I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will most likely subside within 1 to 2 days dependent on lifestyle or any factors listed above. In some cases, bruising can occur. I have been advised that I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration, and exposure to the sun should be limited for up to 2 weeks following the infusion process.


   ______ I understand that immediately after the procedure, the enhancement may be 40% to 60% darker than

the desired result and may take between 4 to 10 days to lighten. I understand that the true color will be visible approximately 1 month after each application, and that the color may vary according to skin tones, skin type, age, and skin conditions.  I acknowledge that some skins accept color more readily than others, and no guarantee of an exact effect or color can be given.


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


   ______I understand that there are few effective methods for pigment removal. Laser removal has proven successful, however is a process, which may take some time.


   ______ I agree to inform my doctor of my permanent cosmetic enhancement if I require a MRI scan within a 3 month period of receiving the procedure.


   ______ I have been quoted the cost of today’s procedure and understand that future touch-up rates and/or policies are subject to change.


   ______I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner, employee, or contractor of Pashyra -The Beauté Bar, LLC. I understand that infection and possible scarring can occur if I do not adhere to the said instructions.


   ______ I understand that Pashyra -The Beauté Bar, LLC can release me as a client at any given time with or without a reason.


    ______ I understand that Retin A, Renova, Alpha Hydroxy, Glycolic Acids, Aloe, and Vitamin E products must not be used on the treated areas or forehead area during healing.


   ______ To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time.


   ______ For the purpose of documentation, I also consent to the taking of “before” and “after” photographs

of said procedure(s). I give my consent for before and after pictures to be used for marketing.


.


 INDIVIDUAL CONSENT



I declare that I give my full consent to the placement of tattoo carried out by the aforementioned practitioner   of Pashyra -The Beauté Bar, LLC.  I confirm that potential complications, e.g. infection and swelling, for the  procedure undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me, and I agree that it is my responsibility to read this and follow the instructions on it until the area treated has healed. 


I certify that I have read or have had read to me the contents of this form.  I understand the inherent and unforeseeable risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered.  I acknowledge that I have reviewed and approve the material given to me, and I authorize Pashyra -The Beauté Bar, LLC     to perform on my body the procedure desired today.


I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e. 18 years old for tattoos), and that I am not currently under the influence of alcohol or drugs.


I CERTIFY THAT I HAVE READ, HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM  AND  THAT  I  HAVE REQUESTED  TO  HAVE PERMANENT  COSMETIC ENHANCEMENT OF MY OWN FREE WILL.




Client Name   _______________________     Signature ___________________________           Date _____


CANCELLATION/RESCHEDULING POLICY

 

Pashyra -The Beauté Bar, LLC’s calendar for permanent makeup is currently booked out 30 day in advance.  When an appointment is made, 3 hours has been blocked off for each client and others have been turned away. Canceling or rescheduling within 10 days may not allow be Pashyra -The Beauté Bar, LLC sufficient time to find someone else to fill in the slot, resulting in forfeiture of monies paid.  Please review your schedule thoroughly before booking an appointment.  If you need to reschedule your appointment, you must do so AT LEAST 10 days prior to your appointment date. All cancellations/rescheduling within 10 days are subject to a rebooking fee.

 

  • Rescheduling within 10 days – $25 rebooking fee (will not be applied towards current or future services)

  • Rescheduling within 48 hours – $50 rebooking fee (will not be applied towards current or future services)

  • NO CALL/NO SHOW - $50 rebooking fee (will not be applied towards current or future services)

 

*PLEASE NOTE THAT ALL DEPOSITS ARE NON-REFUNDABLE/NON-TRANSFERRABLE.  IF YOU RESCHEDULE A TOTAL OF 3 TIMES BETWEEN THE INITIAL SERVICE AND TOUCH-UP SESSION, YOU WILL NO LONGER BE A CLIENT OF PASHYRA -THE BEAUTÉ BAR, LLC.*

 

I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE CANCELLATION/RESCHEDULING POLICY.

 

Client Name  _______________________               Signature  _______________________       Date  _______________________    


Please fill out the following table with a check to indicate if any of the following relate to yourself.


Abnormal Heart Condition


Palpitations


Mitral Valve Prolapsed


Heart Murmur


Rheumatic Fever


Pacemaker


Artificial Heart Valves


Anemia


Hemophilia


Prolonged Bleeding


High Blood Pressure


Low Blood Pressure


Circulatory Problems


Diabetes


Epilepsy


Fainting Spells or Dizziness


Thyroid Disturbances


Liver Disease


Kidney Disease


Glaucoma


Stomach Ulcers


Tumors, Growths or Cysts


Cancer


Tuberculosis


Stroke


HIV


Prosthetic Hip or Joint


Systemic Lupus Erythematosus


Hepatitis


Shingles


Seizures


Impetigo


Cataracts


Blurred Vision


Dry Eyes


Do you suffer from eye Infections


Alopecia


Ocular Herpes


Watery Eyes


Contact Lenses


Eyelid Surgery


Chapped Lips


Trichollomania


Recent Hair Loss


Cold Sores (herpes simplex)


Auto immune conditions


Gore-Tex Implants/Silicone Injections


Other Tattoos


Fat Injections


Bruise or Bleed Easily


Botox Enhancement


Use of Sun bed


Dermal Fillers i.e restylane


Date of last eyelash/ eyebrow tint


Do you have Healing Problems


Chemical or laser peel within 6 months


Do you scar in a raised manner?


Retin A within 6 months


Do your scars heal a darker color


AHA preparations within last 2 weeks


Keloid Scars


Sensitivity to Cosmetics


Acutance within 6 months


Do you tan regularly?


Steroids within 6 months


Asthma




OTHER CONDITIONS: ________________________________________________________________


  Please list any medications you are currently taking or have taken in the past 6 months:   _________

  ____________________________________________________________________________________



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


Client Name   _______________________        Signature  _______________________        Date   _______________________                                                                       

Client Medical History Form


Date___________ Birth Date_____________ Age______ DL or ID# _____________________________

Name: ______________________________________________________________________________

Address: __________________________________City__________________State______Zip________

Phone #________________________Email_________________________________________________


Emergency contact person________________________________Phone#________________________


Do you presently have or previously had any of the following: (Circle YES or NO)


Yes No History of MRSA

Yes No Alcoholism

Yes No Abnormal Heart Condition

Yes No Tumors/ Growths/ Cysts

Yes No Do you give blood?

Yes No Pregnant now/ Breast feeding now

Yes No Oily Skin

Yes No Currently smoke

Yes No Take meds (such as numbing injection) before dental work

Yes No Difficulty numbing with dental work

Yes No Prior to dental procedures, do you receive antibiotic therapy?

Yes No Surgeries in the last year?

Yes No Cancer (Year: ________)

Yes No Chemotherapy/ Radiation in the last year?

Yes No Accutane or acne treatment (date:________)

Yes No Tan by booth or sun (date:________)

Yes No Brow or Lash tinting (date:________)

Yes No Forehead/Brow lift (date:________)

Yes No Face lift (date:________)

Yes No Taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin, fish oil etc. _______________

Yes No Do you have an MRI scan scheduled in the next 3 months?

Yes No Do you have a Laser or IPL scheduled in the next 3 months?

Yes No Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?

Yes No Allergic reaction to any of the following medications:  Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl      

              alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, etc.

Yes No Allergic reaction to any of the following:  antibiotic ointments, metals, latex, rubber, hair dye, paints, nuts,

              medication, drugs, foods, crayons, glycerine?

Yes No Any diseases/disorders/conditions/allergies not listed? ________________________________________________



LIFESTYLE:

  • How many times per week do you work out or go in the sauna (if any)?__________________________

  • How often are you in the sun for more than 30 minutes? (i.e tanning, outdoor activities, running, gardening etc.)_______________________________________________________________________

  • Do you get facials, peels, microdermabrasions etc?  If so, how often?____________________________

  • How often do you go swimming?_________________________________________________________



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



Client Name _______________________          Signature_______________________         Date _______________________                                                                    


CANCELLATION/RESCHEDULING POLICY

 

Pashyra -The Beauté Bar, LLC’s calendar is currently booked out 30 days in advance. If you reschedule your appointment, please keep in mind that you might not be able to make another one until 1 to 2 months out. Please review your schedule thoroughly before booking an appointment. If you need to reschedule your appointment, you must do so AT LEAST 10 days prior to your appointment date. All cancellations/rescheduling within 10 days are subject to a rebooking fee.

 

  • Rescheduling within 10 days – $25 rebooking fee (will not be applied towards current or future services)

  • Rescheduling within 48 hours – $50 rebooking fee (will not be applied towards current or future services)

  • NO CALL/NO SHOW - $50 rebooking fee (will not be applied towards current or future services)

 

©2019 by Pashyra LLC.