ONCE THE TINY TATTOO & NON-REFUNDABLE DEPOSIT CONSENT FORM 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 Date of Birth * MM DD YYYY Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Today's Date * MM DD YYYY Select Your Technician's Name * Andreea Furtado Please Select Tiny Tattoo Size Below * Small (Under3") Medium (3-5") Large (Over 5') Please give a brief description of your desired tattoo Below * Desired Location of Tattoo * Are you pregnant or nursing? * Yes No Do you have a history of cold sores, herpes, or fever blisters? * Yes No Previous problems with tattoos or has your physician advised you not to have a tattoos at this time? * Yes No Are you undergoing/Consuming any of the following treatments/Medications: Aspirin, blood thinners, mood altering drugs, immuno-suppressive medications such as anti-inflammatories or steroids, Radiation/Chemotherapy? * Yes No Are you allergic to ANY of the following: Topical antibiotic preparations or de-sensitizers, latex, metal? * Yes No PLEASE READ AND AGREE BELOW * I understand that a certain amount of discomfort is associated with this procedure, and possible adverse side effects may include: minor & temporary bleeding, bruising, redness or other discoloration and/or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur. I understand that for certain tattoo's a touch up might be required to achieve my desired results. I understand that all touch ups are an additional fee. 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 desire for specific color, shape, and/or position for any procedure done today. I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. I understand that fine line tattoos are superficial and the tattoo color may slightly change or fade over time due to circumstances beyond my artist’s control and that I will need to maintain the color/shape with future applications. 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 understand that I will have the opportunity, within the time constraints of my appointment, to approve the design and color of the tattoo to be applied, and I accept responsibility. I have been given an estimate of the cost of the procedure. 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 for any reason. 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 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. EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. It typically disappears within 1-5 days. Bruising or swelling may not occur. ALLERGIC REACTION: There is a small possibility of an allergic reaction. You may take a 5-7 day patch test to determine this. I am over the age of 18, I am not under the influence of drugs or alcohol and desire to have a tattoo to be performed. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. ** I have been informed of the nature, risks and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and the spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the Tattoo procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each Individual's reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent. * I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent tattoo. I acknowledge some of these potential adverse changes may not be correctable. * I have reviewed pre and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. * I understand that taking of before and after photographs of the said procedure are a condition of such procedure. I certify I have read and agreed to each of the above paragraphs and have been explained to my full understanding of this consent and procedure process. I accept full responsibility for the decision to have the cosmetic tattoo work done. * Office Policies: I agree to BR Brows and Beauty's cancellation and etiquette policies. I understand that a $200/$100.00/$50.00 dollar Non Refundable deposit is required to secure my initial appointment. 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 cancellation fee. Additionally, children under the age of 18 are NOT permitted in the office. I understand that by violating office policies, BR Brows and Beauty has the right to refuse service or charge me, the client, a fee (stated above). 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/$100.00/50.00 as a NON-REFUNDABLE DEPOSIT in order to book a LG Tiny Tattoo($200.00)/Med Tiny Tattoo($100.00)/and/or $50.00 NON-REFUNDABLE DEPOSIT for SM Tiny Tattoo Services. 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/$100.00/50.00 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 I AGREE 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!
