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Client Pre-Procedure & Precautionary Corona Virus Liability Release Form

 

 

 

Precautionary Corona Virus Liability Release Form

 

Due to the 2019-2020 outbreak of the novel corona virus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below.

 

Symptoms of COVID-19 includes:

Fever                                     
Fatigue
Dry Cough
Sore Throat
Muscle Pain
Headache
Chills
Difficulty Breathing
New loss of Taste or Smell

 

I,

 Agree to the following:

 

I Agree
I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

 

I Agree
I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days.

 

I Agree
I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

 

I Agree
I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.

 

I understand that this business (Chyna Thi Brow Art / Salon 77 West) and my PMU artist Chyna Padilla cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

 

By signing below, I agree to each above statement and release the PMU artist and business from any and all liability for the unintentional exposure or harm due to COVID-19.

 

Your PMU artist and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

 

 

 

Signature

       Date May 2, 2024

 

 

Possible Risks, Hazards, or Complications

 

• Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others.

 

• Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See “Aftercare” section in chynathi.com for instructions on care.

 

• Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance.

 

• Asymmetry: Every effort will be made to avoid asymmetry, but our faces are not symmetrical so adjustments may be needed during the follow-up session to correct any unevenness.

 

• Excessive Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don’t bruise or swell at all.

 

• Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now.

 

• MRI: Because 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 MRI Technician of any   tattoos or permanent cosmetics.

 

The alternative to these possibilities is to use traditional cosmetic and NOT undergo The Semi‐Permanent Eyebrow procedure.

 

 

Consent and release for procedures performed:

 

Signature 

 Date May 2, 2024

 

Consent and Release Agreement

 

This form is designed to give information needed to make an informed choice of whether or not to undergo a  semi-permanent makeup application. If you have any questions, please don’t hesitate to ask.

 

Although the semi-permanent makeup procedure is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

 

This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent.

 

All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after use. Cross contamination guidelines are strictly adhered to.

 

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual and advised to expect a Touch-Up after healing is completed.

 

Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time. 

 

Additional Touch-Ups are likely needed within 6 months to 2 years.

 

Signature

Date May 2, 2024

 

Photography Release Consent

We would like your permission to use your photos for our portfolios, instagram and ads, etc.

I Agree
I give you my permission to use my photos.

 

Statement of Consent and Recitals

Please read and initial all lines


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 Acid must not be used on treated areas.  They will alter the color and cause premature exfoliation of the pigment.


I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup.


I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue.


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


I accept the responsibility to explain to you my desire for specific colors, shape, and position for any procedure done today.


I understand that implanted pigment color can slightly change or fade overtime due to circumstances beyond your control, and 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 possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.


I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention.  

I certify that I have read all the contents of this form.  I understand the risks and alternatives involved in the procedure(s).  I have had the opportunity to ask questions, and all of my questions have been answered.  I acknowledge that have reviewed and approved the material given to me, and I authorized Chyna Thi, as my Permanent makeup artist to perform on my face/body the semi-permanent makeup procedure desired. 

 

Signed

 Date May 2, 2024

 

 

 

 

 

 

 

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Medical Questionnaire - Do you have or previously had any of the following:
History of MRSA*
No
Yes
Botox within the last 2 weeks*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Facelift*
No
Yes
Abnormal Heart Condition*
No
Yes
Chemical Peel within the last 2 weeks*
No
Yes
Pregnant now - Breastfeeding now*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Accutane within the last year*
No
Yes
Currently undergoing chemotherapy/Radiation*
No
Yes
Taken blood thinners in the 72 hours such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes
HIV*
No
Yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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