Consent Form
Name:_____________________________
Date:_____________________________
Phone:_____________________________ Email:_____________________________
How did you hear about Pashyra – The Beauté Studio:
_______________________________________________________
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 during the procedure(s), I further request and authorize Pashyra - The Beauté Studio, LLC to use its full judgment and do whatever is deemed advisable and necessary in the circumstances without any liability to Pashyra - The Beauté Studio, 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 therefore 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 6 weeks after the initial procedure, and that after the 6-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 Studio, 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 Studio, 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 Studio, 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 The Beauté Studio, 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 Studio, 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 Studio, 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 STUDIO, 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 _____
ARRIVAL TIME
Please arrive to your appointment at least 5 minutes prior to the scheduled time. All services offered have a specific time schedule, and early arrival allows for a relaxed and unhurried experience. If late arrival is inevitable, your service(s) may be shortened in order to stay on schedule.
LATE ARRIVAL POLICY
All appointments begin and end on time so that the next client is not delayed. If the procedure does not start on time, the procedure time will be reduced accordingly, and you will still be required to pay full price. If a client is more than 15 minutes late, we may require that the appointment be rescheduled, and it will be considered a cancellation. We regret that late arrivals will not receive extension of scheduled appointment time. In special cases, and when our schedule will allow, we may be able to accommodate a partial or full appointment. This will be at our discretion and only with advanced notification of late arrival.
PAYMENT POLICY
We accept cash, debit/credit cards and cashapp. All services must be paid in full at the time of visit.
EYEBROWS AFTERCARE
Aftercare compliance is especially important for producing a beautiful and lasting result. Please follow the guidelines as instructed by your technician to obtain the best results.
No water, cleansers, creams, makeup, or any other products on treated area for 10 days or until all peeling is done.
Keep the area LIGHTLY moist using a q-tip with sterile Aquaphor (very lightly and not overly greasy). Apply as needed ONLY when it feels dry or itchy.
Expect slight swelling and a little redness in the immediate area. This will subside in a few hours.
If slight crust appears on the pigmented surface, DO NOT force removal by picking or scratching.
Don’t be alarmed if color comes off on the q-tip when applying the ointment -- this is normal.
Avoid hot, steamy, long showers (leave the door cracked opened if you are able to).
Avoid working out for the next 7-10 days or until all scabbing has completed.
No makeup on or around the brow area during the healing process.
Avoid tinting of brows for 3 weeks following the procedure.
The procedure may have some peeling on or around the 4th day. This is a normal process of healing for some clients. DO NOT PICK! Picking can cause scarring and loss of color.
Avoid sun for 7 to 10 days following the procedure. It is suggested to wear a hat if you are expected to be out in the sun for a long period of time. Do not let the brim of the hat touch your brow area.
Be mindful of how you sleep, if you can avoid sleeping on your side or stomach, it is suggested to do so. Sleeping on your back is recommended.
Avoid chlorine pools, saunas and Jacuzzis, hot yoga, hair dryers, and any steam-like environment etc.
Avoid Retin A, Renova, Alpha Hydroxy, Glycolic Acids, Aloe, and Vitamin E products.
No Gardening for the first 3 to 4 days to prevent possible infection.
If you are planning a chemical peel, MRI, or other medical procedures inform them that you have had an iron oxide cosmetic tattoo.
You must wait 1 year after any tattoo to give blood. This is state specific – you can check on the American Red Cross to see the rules for your state.
Lasers can cause pigment to turn black. Avoid the procedure site.
After you have healed, use a good sunscreen daily to help prevent premature fading of all procedures (wait to do this after your touch up session).
If any signs of infection occur, abnormal swelling, redness or pain associated with the procedure, call your physician and please give us a call.
The application of permanent cosmetics can be a 2 to 3 step process. Do not judge your procedure while in the healing stage. It may require a touch up or multiple touch-ups as everyone heals differently. The procedure area has to heal completely before we can address any concerns. Healing takes about 4 weeks.