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Permanent Makeup Consent Form

Chic Studio
Artist Information (the “Artist”): Amber Siewert
74 Glenhill Place Cochrane AB T4C 1H1

By signing this agreement, I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about Microblading (the “Procedure”) and that all of my questions have been answered to my full satisfaction by the Artist, as named above, who will be performing the Procedure. I specifically acknowledge that I have been advised of the facts and matters set forth below.

I am over the age of nineteen (19) and I have truthfully represented to the Artist that undergoing the Procedure is by my choice alone.

I Agree

I understand that the Procedure is risky and I am having it done at my own risk. 

I Agree
.

I am not pregnant or nursing. 

I Agree

I am not under the influence of drugs or alcohol. 

I Agree

I do not use blood thinners or any other medications that increase bleeding time. 

I Agree

I do not have skin conditions such as acne, eczema, psoriasis or any other skin sensitiveness in the Procedure area. 

I Agree

I do not currently have cancer. I am not undergoing chemotherapy and I have not undergone chemotherapy in the past 12 months. 

I Agree

I do not have diabetes, keloid scarring, a history of hemophilia/abnormal bleeding, or any medical condition that might affect the healing of the Procedure area. 

I Agree

I do not currently take Acutane or any other acne medication and I have not taken Acutane or any other acne medication for the past 12 months. 

I Agree

I do not currently have any type of infection or rash anywhere on my body. 

I Agree

I do not have freckles, moles or sunburn in the Procedure area. 

I Agree

I do not have any sensitivity to dyes or local anesthetics (for example; lidocaine or prilocaine) or epinephrine. 

I Agree

I do not have Covid, nor have I had exposure or have had a positive test result in the last 14 days. 

I Agree

I have received the aftercare instructions and I agree to follow them. I also agree that if I do not follow the instructions, any touch-up needed will be done at my own expense. 

I Agree

I consent to have the Artist perform the Procedure and also any actions or conduct that are reasonably necessary to perform the Procedure. 

I Agree

I acknowledge that:
I might have an allergic reaction to the pigments, or anesthetic numbing cream used in the Procedure and I accept the risk that such a reaction is possible.
Infection is always possible as a result of the Procedure, particularly in the event that I do not take proper care of the area following the Procedure. 

I Agree

Variations in color exist between the color selected and how it will ultimately look when my eyebrows have healed. I also realize that the Procedure area will be dark for approximately the first six (6) days and will lighten thereafter. 

I Agree

The final result will not be obtained without a touch up visit to reshape or augment areas within the brow. This is usually done no sooner than four (4) weeks after the initial visit.
The final appearance of the brow will be achieved 6-8 weeks after the final visit. 

I Agree

The Procedure will result in a semi-permanent change to my appearance (which usually lasts between 8 months and 3 years). Some pigment may forever remain under the skin and no representation has been made to me as the ability to later change or remove the results. Skin treatments such as laser hair removal, plastic surgery or other skin altering Procedures may result in adverse changes to the Procedure area. 

I Agree

Liability
The Client acknowledges that the Artist will take all necessary precautions to protect the Client during the Procedure and that the Artist is not a medical professional even if they carry a secondary designation as a registered massage therapist (RMT). The Procedure is not within the scope of practice of a RMT.
The Artist shall not be liable for any direct, indirect, special, consequential, or exemplary damages or injury to the Client resulting from, or in any way connecting to the Procedure.
__________ I Agree. (Client initials) 

Risks
The Client acknowledges and assumes all risks inherent or in any way relating to the Procedure and agrees to take all necessary precautions to protect the Client from all damage and injury that could arise from the Procedure.
The Client is fully aware that the Procedure is inherently dangerous and that such Procedure is subject to mishap, injury and possibly even death.
The Client acknowledges that no warranties, either express or implied, have been given concerning the safety of the Procedure or the skills of the Artist.
__________ I Agree. (Client initials) 

Covid Safe
I understand that I will wear appropriate personal protective equipment (face mask), or will be provided one at an additional charge. I understand the Artist and The Glamour Room follows strict AHS public health seriously.

___________I Agree. (Client initials)

Release
The Client hereby releases the Artist, its principals, agents, and employees, from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, which the Client now has or which hereinafter may have, against the Artist by reason of or in any way related to the Procedure.
The Client agrees to indemnify and hold harmless the Artist, its principals, agents, and employees from any and all liability, actions, causes of action, claims, loss, demands, damages, or injury, including legal costs, loss of profit, or other special or consequential damages, or injury, including legal costs, loss of profit, or other special or consequential damages, howsoever arising, resulting from, or in any way connected to, the Procedure.
__________ I Agree. (Client initials) 

Care and Maintenance
I agree to follow the care and maintenance instructions provided by the Artist for the care of the Procedure area following the Procedure, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk. I understand that failure to follow aftercare instructions may result in permanent damage to my skin, scarring and may prevent the pigment from settling. I agree to keep the Procedure area clean and to follow aftercare instructions.
__________ I Agree. (Client initials) 

No Known Medical Conditions / Informed Consent
I have read and completed the Procedure Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as keloid scarring, or infection) that the Procedure may cause to those who have specific medical or skin conditions. I understand that in rare cases persons may be allergic or have hypersensitivity to some of the products used during the Procedure. I understand that allergies to pigments may develop at any time after the Procedure, while the pigment is implanted in my skin. I further state that I have no known medical condition that might be aggravated by the Procedure or any medical condition that would prevent me from complying with or heeding to the Artist’s instructions or these warnings.
__________ I Agree. (Client initials) 

Spot Test
I understand, that should I have any concerns about any possible reaction to the chemicals and products used, I may arrange at my own discretion to book an advance spot test where topical anaesthetics and pigment will be applied to my skin externally, 24-48 hours prior to the time in which I’m scheduled for the Procedure. I also understand that spot testing does not guarantee that no future sensitivity or reactions will develop. I agree that scheduling a spot test shall be my own responsibility and at my sole discretion, and have absolutely no bearing on the contents or signing of this Agreement or any clauses contained therein.
__________ I Agree. (Client initials) 

Cancellation Policy
I understand that the appointment time is reserved for the Client. A late cancellation or missed visit leaves a hole in the Artist's day that could have been filled by another client. The Artist requires 24 hours notice for any cancellations or changes to your appointment. Clients that provide less than 24 hours notice or miss their appointment will be charged a cancellation fee of the entire cost of the appointment as booked.
If the Client arrives late for their appointment, no additional time will be added to the appointment. The Procedure will be stopped at the scheduled end time of the appointment, regardless as to whether or not the desired outcome is achieved in the remaining amount of time. The client will be charged in full for the service time as booked.
__________ I Agree. (Client initials) 

Permissions to Use Photographs
I hereby grant the Artist the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyebrows, both before and after this Procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary by the Artist. I further expressly assign any copyright in these photographs to the Artist. I also grant my consent for the Artist to use my image and likeness as contained in these photographs for any advertising or other purposes.
__________ I Agree. (Client initials) 

Children
I understand that the Procedure requires the full attention of the Client and the Artist. As such, unattended minor children are not permitted in the Procedure space during your appointment.
__________ I Agree. (Client initials) 

Refunds
I understand that the Procedure and all services rendered by the Artist are non-refundable.
__________ I Agree. (Client initials) 

Design Approval

I approve of the brow shape/design created by the Artist and the colors of pigment selected, and have been given an opportunity to modify the brow shape/design created by the Artist and the color of pigment selected prior to application.
__________ I Agree. (Client initials) 

Declaration
The Client has read this entire document, understands its contents, and knows the truthfulness thereof.
__________ I Agree. (Client initials) 


IN WITNESS WHEREOF the parties have signed, sealed and delivered this Agreement as of the date first above written.

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First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
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City:*
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Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

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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