Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth (Must be 18 years or older)

YYYY

Are you pregnant or breastfeeding?

Yes

Have you ever had a tattoo removal or cover-up?

Yes

Have you had botox or injections in the last 2 weeks?

Yes

History of MRSA or Autoimmune Disorder:

Yes

History of hemophilia or excessive bleeding:

Yes

Diabetes or other conditions which may affect blood circulation and / or ability to fight infection:

Yes

History of skin disease, skin lesions, or skin sensitivities to soaps or disinfectants:

Yes

Do you have any skin conditions, such as eczema, psoriasis, or dermatitis, that may affect the tattoo area?

Yes

History of allergies or adverse reactions to latex, pigments, lidocaine, dyes, disinfectants, metals or other sensitivities related to body art procedures:

Yes

History of epilepsy, seizures, fainting or narcolepsy:

Yes

Treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting:

Yes

Hepatitis A B C D or HIV?

Yes

Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?

Yes

Do you have any pre-existing medical conditions or allergies that we should be aware of before the permanent eyebrow procedure to ensure your safety and to update our insurance records accordingly? If so, please explain:

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

I accept responsibility for any allergic reaction and any risk of fading, fanning, and/or spreading.

Aftercare instructions will be explained to me and a 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:

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 treated areas. They will alter the color premature exfoliation of the pigment:

I understand that tanning beds, pools, some skin care products and medications can affect my tattoo:

I understand that successful pigment retention can NOT be guaranteed due to hidden scar tissue:

I will tell all skin care professionals or medical personnel about my tattoo procedures, especially if I am scheduled for an MRI:

I accept the responsibility to explain to you my desire for changes of the design, including size and placement for any procedure done at the appointment:

I understand that implanted pigment can slightly change or fad over time due to circumstances beyond your control:

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:

AFTER CARE PLAN

It is essential that you follow these instructions after your tattoo session: Upon the end of your service, the artist will have applied a thin layer of aquaphor or grapeseed oil to the treated area. Please leave this ointment on the treated area for a day and do not wash it or add stress to the area. You can keep area covered if advised. For the next 15 days please make sure to repeat the following: Wash and sanitize hands. Gently wash off ointment with DISTILLED water. Be extra careful not to tug or scrub the brows. After gently washing, cleanse brows with Cetaphil Gentle Cleanser, then rinse with distilled water. Apply Aquaphor/ointment on your treated area twice a day The following must be avoided during all 15 days post-procedure: Increased sweating Practicing sports Swimming Hot sauna, hot bath, or jacuzzi Sun tanning or salon tanning Any laser or chemical treatments or peelings, and/or any creams containing Retin- A or Glycolic Acid on the face or neck Picking, peeling, or scratching of the micro pigmented area in order to avoid scarring of the area or removal of the pigment Performing tasks related to heavy household cleaning such as garage or basement cleaning where there is a lot of airborne debris Smoking Drinking alcohol in excess, as it may lead to slow healing of wounds Driving in open air vehicles such as convertibles, boats, bicycles, or motorcycles Touching of the eyebrow area except for when rinsing and applying the post-carecream with a cotton swab Before showering apply a layer of post-care cream to protect your eyebrows from moisture. During the shower keep your face away from the shower-head.Itchiness and flaking may occur during the first seven days post-procedure. However, experience has shown that by following these after-care instructions, these symptoms may quickly disappear.The healing will last between 18-25 days. Touch-ups and/or correction of the shape-design is necessary only after this period.If you have any unexpected problems with the healing of the skin, please contact me at 484-425-7575 or nohanabrowstudio@gmail.com to discuss further instructions.Once completely healed, always apply a layer of sunscreen SPF 30 up to SPF 50 on your eyebrows when exposed to the sun. Sun exposure might cause the color pigment to fade away more quickly. Please consult a physician at any indication of infection.

PERSONAL APPEARANCE

Are you comfortable with showing your face in photos or videos?

Yes

Design Location

Before Your Appointment

PMU Waiver