Permanent MakeupPlease review and fill out this intake form after booking any permanent makeup tattooing services. Read over the policies here prior to booking. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Cover-up Service Do you have/had previous brow permanent makeup work by another artist? * Please check which applies to you. No. Yes. I have completed the Pre-Screen Form for Cover-up Service under the 'Services + Pricing' tab at bookstudiokb.com. Medical Questionnaire Birthdate * MM DD YYYY If a contraindication applies to you, you may not be able to receive service. Please check any of the following that apply to you. Under the age of 18 COVID-19 Vaccine in the last 2 weeks Pregnant or nursing Problems with healing Chemical peel or laser peel in the last 6 weeks Exfoliating acid or retinoid (Retin-A) products within 48-72 hours Botox or fillers in the last 2 weeks Accutane within the last year Blood thinning agents Wear contact lens or false lashes Previous work done by another artist History of herpes, cold cores or fever blisters History of skin disorders or remarkable skin sensitivities History of MRSA Hepatitis (B or C) AIDS/HIV Diabetes Autoimmune disorder Bleeding disorder Epilepsy Alopecia Brow tinting Dry eyes Glaucoma, eye surgery, eye injury, or corneal abrasion Hyper-pigmentation Hypo-pigmentation Scarring/keloid formation Oily skin Tanning - tanning bed or sunbathing Allergic reactions to metals, Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Propylene glycol, Vitamin E Acetate Please list any other allergies you have. Please list any medications you are currently on. Please list any illnesses or medical conditions you are currently being treated for by a medical professional, including current treatment for cancer. Consent Please submit. * If an unforeseen condition arises in the course of the procedure, I authorize Khrista to use her professional judgement to decide what she feels is necessary under the given circumstances. I accept responsibility for approving the color, shape, and position of the pigments that will be applied as agreed upon during the consultation. I understand tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and that the health consequences of using these products are unknown. I understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of one to three years. These results vary and I understand that no time frame is guaranteed to me. Even once the color fades, pigment itself may stay in the skin indefinitely (permanent). I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I may have to return for a repeated procedure. I understand that this is a cosmetic tattoo and within time pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, and use of chemicals such as Retin-A and Glycolic Acids. Touch-up maintenance work will be expected in the future to keep this procedure looking fresh. I have been advised that the true color will be seen six to eight weeks after each procedure and that the pigment may vary according the skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given. I understand the nature of the procedure and adverse effects that may occur as a result of applied pigments. Adverse effects include: redness, swelling, puffiness, corneal abrasions, dark patches, allergic reactions, tenderness, infection, or migration. In addition, I understand that there is a possibility of hyper pigmentation or scarring resulting from a procedure, especially in individuals prone to hyper pigmentation from a scar or other injury. I understand that topical anesthetics will be used for my comfort. If I am allergic, I will make any such allergies or contraindications that I may haven known to Khrista prior to the procedure. I have been informed that the highest standards of hygiene are met and that sterile disposable needles and pigment containers are used for each individual client, procedure, and visit. I agree that I have read the FAQs on this website and understand the maintenance and aftercare instructions that been provided and explained to me by Khrista. I understand that achieving the results I desire will, in some measure, be determined by my compliance to these instructions. I have been given the opportunity to ask questions about the procedure, equipment, past experience, and the methods to be used, as well as, the risks and hazards involved. I believe that I have sufficient information to give this informed consent. I understand the taking of before and after photographs of procedures maybe required and that some photographs may be taken during the procedure. I also understand that exceptional photographs or results may be used in advertising or promotional materials and give permission for such usage. - I have read and fully understand the above information. I have given an accurate account of the questions. If I have any concerns, I will address these with Khrista. I give permission to Khrista to perform the service we have discussed. I agree to adhere to the aftercare instructions as recommended by Khrista. I understand that Khrista will take every precaution to minimize or eliminate negative reactions as much as possible. Despite all precautionary measures Khrista takes, injury is possible. I will hold Khrista harmless from any liability, responsibility, damages or issues that may result from this service. Yes, this submission certifies that I agree to all clauses above. No, I do not agree to all clauses above. Date * MM DD YYYY Thank you for submitting.
