ONCE THE LIP BLUSHING CONSENT, HERPES SIMPLEX DISCLAIMER, & NON-REFUNDABLE DEPOSIT CONSENT IS COMPLETED YOU WILL THEN CHOOSE YOUR DATE AND SERVICE(YOUR FORM WILL ONLY BE SAVED AFTER REQUESTING YOUR APPOINTMENT)* Name * First Name Last Name Phone * Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Last Lip Filler Treatment Must wait 4 weeks after fillers before lip blushing procedure. Clients who have suffered from cold sores (Herpes simplex 1) can experience symptoms of the infection after treatment to the lips. Many are not aware that they are a carrier of this virus, as signs are not always visible until it is triggered. We HIGHLY Recommend all clients undergoing Lip Blushing to use Antiviral medication pre and post their procedure. Medications such as Valtrex : (should be started 4/5 days prior to your appointment and 3-4 days after the treatment). Cold sores are a typical reaction in permanent makeup of the lips. I am fully aware that permanent make up causes a cold sore outbreak reactivation in up to 90% of the cases. * Do You Have a Known History of Cold Sores? Yes No PLEASE READ AND AGREE BELOW* I understand that it is my sole responsibility to obtain an Antiviral prescription from my primary care physician in order to be properly prepared for my lip blushing appointment. I acknowledge and understand that if I choose not to obtain said prescription it can directly effect my results. I also acknowledge that my provider will not be held accountable if I do break out with a cold sore post procedure. What can happen if I choose not to take an Antiviral Script? * Poor Pigment Retention * Infection * Excess Scar Tissue * Cold Sore Outbreak * Undesirable Outcome What can happen if I choose not to take an Antiviral Script? * Poor Pigment Retention * Infection * Excess Scar Tissue * Cold Sore Outbreak * Undesirable Outcome I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur. I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. I will disclose to all skin care professionals or medical personnel about my permanent makeup procedures, especially MRI procedures. I accept the responsibility to explain to my technician any desires for specific color, shape, and/or position for any procedure done today. I understand that implanted pigment color may slightly change or fade over time due to circumstances beyond control and that 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 the possibilities of complications during and/or following the procedures such as infection, misplacement, pigmentation, poor color retention and hyper-pigmentation. I have been given an estimate of the cost of today’s procedure. It is recommended that a touchup appointment be scheduled between 10-12 weeks thereafter. I understand there are no refunds for the elective procedure(s). I understand that any deposit made towards said procedure(s) will not be refunded if I choose to cancel my procedure. I understand that all touchup appointments are an additional charge. Possible Risks/Hazards/Complications: * PAIN: There could be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. INFECTIONS: Infection is very unusual. Less than 0.25% of the population has an allergic reaction. The areas treated must be kept clean and only touched with freshly cleaned hands. See "After Care for Lip Blush" for instructions. UNEVEN PIGMENT: This can be a result of poor healing, infection, bleeding, or other causes. Your follow up appointment will likely correct any uneven appearances. ASYMMETRY: Every effort will be made to avoid asymmetry, but our faces are asymmetrical and adjustments may be needed during the follow up session to correct any unevenness. EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. It typically disappears within the first few days. ANESTHESIA: Topical anesthetics are used for numbing the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform your technician immediately. MRI: 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. ALLERGIC REACTION: There is a small possibility of an allergic reaction. You may take a 5-7 day patch test to determine this. Yes, I have read and understand the possible risks, hazards and complications. Lip Specific Cautions: * Herpes Simplex Virus: If you have an outbreak, you must reschedule your appointment and wait until it has healed at least 6 weeks. If you have a history of cold sores, please ask your doctor for an antiviral medication and take them 5 days before treatment and 5 days after. Lip blushing can trigger cold sores! Hyperpigmentation: Most commonly seen in African, Caribbean, Mediterranean, Asian and Latin skin types. Understand that the risk of the procedure may cause hyperpigmentation, but will be treated very carefully. Chapped Lips: Please follow the Pre-Care Instructions to exfoliate 1 week for everyday until appointment and hydrate. The lips must be a clean canvas for good pigment retention and healing. Yes, I have read and understand the possible risks, hazards and complications. Medical Conditions (from low to highest priority) * Allergies, alopecia, anemia, aspirin, asthma, hx of cold sores, hyperpigmentation, thyroid, trichotillomania (can be treated with caution) Accutane, alcohol, Antabuse, breastfeeding, chemical peels, chapped lips, cuts or abrasions, epilepsy, injectable fillers, present inflammatory skin conditions on the treated area, Retin A, scar atrophic, shingles (must wait before treating) Artificial heart valves, autoimmune conditions, antibiotics for dental treatment, blood thinning medications, bruise and bleed easily, cancer, diabetes, hemophilia, HIV/AIDS, high blood pressure, kidney and/or liver disease, palpitations, vitiligo (need doctor’s consent) Allergies to permanent make up, birthmarks/port-wine stains on lips, body dysmorphia, contagious disease, hepatitis (A, B, and C), active herpes simplex, latex allergy, lupus, pregnancy, skin heals dark with minor injury*, scar hypertrophic from minor injuries, scar keloid from minor injuries (cannot treat) Yes, I have read and understand the possible risks, hazards and complications. If you Cancel or Reschedule your touch up for ANY reason, and you cannot make it in for your initial touch up appointment WITHIN 2 MONTHS FROM YOUR FIRST VISIT. You will be CHARGED an additional touch up price of 500.00. * Office Policies: * I agree to BR Brows and Beauty's cancellation and etiquette policies. I understand that a $200.00 dollar Non Refundable deposit is required to secure my initial appointment. Additionally, children under the age of 18 are NOT permitted in the office. I understand that if I am not properly prepared for my appointment, my provider has the right to refuse service. I acknowledge and understand that if service is refused for said reason I am responsible to pay a Cancelation fee of $100.00. I understand that a 48-hour notice is required for all cancellations. If you Do Not Cancel within 48hrs to your scheduled appointment time, For ANY REASON a fee of $100.00 will be automatically charged to the card on file. It is REQUIRED that all Clients have a card on file (please provide card info below). If a client does not show for an appointment or does not give proper notice after the second time, the next appointment is REQUIRED to be paid in full. If a client comes in for a pre booked service and decides to decline getting said procedure done, you are required to still pay the Full Service Fee. Clients who do not confirm their appointments through our reminders or confirm through text and phone calls will be removed, and replaced with a client on the cancellation list and charged the cancelation fee. Non-Refundable Deposit Consent: Please read and check the box below. The undersigned, hereby agree to pay BR Brows + Beauty the amount of $200.00 as a NONREFUNDABLE DEPOSIT in order to book a LIP BLUSHING Service. The undersigned, acknowledges, understands, and agrees that if he/she chooses to cancel said appointment at any point in time after making said deposit, THAT ALL DEPOSITS AND PAYMENTS MADE TO THAT POINT SHALL BE FORFEITED WITH NO REFUND OFFERED. The undersigned have been informed of this policy verbally, and consent to paying the $200.00 Non-Refundable deposit. The undersigned, acknowledges that there are no exceptions in which BR Brows + Beauty would refund said Non-Refundable deposit. The undersigned acknowledges, understands, and agrees that said deposit is NOT a credit, and that Deposits made are NOT transferable to other clients. By signing below, the undersigned, acknowledges, understands, and agrees to BR Brows + Beauty’s Non-Refundable Policy. I understand and accept BR Brows + Beauty's Non-Refundable Deposit Policy. * * I AGREE AND UNDERSTAND THE ABOVE TERMS AND ASSUME ALL RESPONSIBILITY COUPON CODE I give my consent to make this my default Credit card for all digital and in-person payments. * Expiration Date: * Security Code (CVV) REQIRED * Digital Signature * **ONCE APPOINTMENT REQUEST IS ACCEPTED THE CARD WILL BE CHARGED THE DEPOSIT AMOUNT FOR THE SERVICE YOU CHOOSE** Thank you!
