BROW MANTRA

Shop2, 380 Logan Road. Stones Corner. Qld 4120
www.browmantra.com.au. P:07 3397 6111. E: info@browmantra.com.au

Client Medical History

*Title

Miss

Mrs

*First Name

*Last Name

*Date of Birth

*Mobile Number

*Email

*How did you hear about us?

*Street No

*Street Name

*Suburb

*Emergency Contact (Name)

*Emergency Phone Number

Do you presently have or previously had any of the following: (Circle yes or no)

Botox

Yes

Diabetes

Yes

Hepatitis (A,B,C,D)

Yes

Forehead/Brow Lift

Yes

Easy Bleeding

Yes

Facelift

Yes

Alcoholism

Yes

Abnormal Heart Condition

Yes

Take Meds Before Dental Work

Yes

Chemcial Peel

Yes

Pregnant Now/Breastfeeding Now

Yes

Brow or Lash Tinting

Yes

Autoimmune Disorder

Yes

Oily Skin

Yes

Cancer Year

Yes

Accutane or Acne Treatment

Yes

Chemotherapy/Radiation/Tan by Booth or Sun

Yes

Tumors/Growths/Cysts

Yes

Old Tatoo on the Treatment AreaIf yes, can affect the final results of the procedure

Yes

Difficulty Numbing with Dental Work

Yes

Taking blood thinners such as: Aspirin, Ibuprofen, alcohol, Coumadin,etc

Yes

Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, etc

Yes

Allergies to metals, food, etc

Yes

Any diseases or disorders not listed

Yes

Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?

Yes

Please list all medications or vitamins you are presently taking:

Have you had any operations? Surgery in the past 12 months?

Yes

Are you planning on having any surgery soon?

Yes

Are you suffering from any other medical conditions/ diseases/ disorders that are not covered above or is there anything else we should know that may affect your treatment?

Yes

This is a true and accurate statement of my medical history, past and present. I am aware that failure to disclose information pertinent to my treatment could have serious health ramifications. I am also aware that failure to disclose information pertinent to my treatment could have a direct bearing on treatment outcome.

Client Name

Signature

*Date

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

Although cosmetic semi permanent make up is affective 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 dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are stickily adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.

Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years.

Signature

*Date

Possible risks, hazards or complications

• Pain: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.

• Infection: Although rare, there is a risk of Infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care” sheet 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. adjustments may be needed during the follow up session to correct any unevenness. 100% symmetry is not possible.

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

• Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.

• MRI: Because pigments used in permanent cosmetic procedures contain iron 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 possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7 day patch test to determine this.

The alternative to these possibilities is to use cosmetics and not undergo the cosmetic semi-permanent make up/ 3D Eyebrow Embroidery (Microblading) procedure.

Consent and release for procedures performed:

Signature

*Date

STATEMENT OF CONSENT AND RECITALS

Please read and initial all lines

Aftercare instructions have been explained to me

Yes

I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur

Yes

I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color

Yes

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

Yes

I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI

Yes

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

Yes

I am aware that I cannot give blood for 6 months

Yes

I accept the responsibility to explain to Nikki Randhawa my desire for specific: A. colours, B. shapes and C. positions for any procedure done today.

Yes

I understand that the implanted pigment colour can slightly change or fade over time due to circumstances beyond my or Nikki Randhawa’s control. I will need to maintain the colour with future applications and a touch up session within 60 days

Yes

I acknowledge that the procedure involves risks including but not limited to infection, misplaced pigment, poor colour retention and hyper- pigmentation

Yes

I acknowledge that the procedure involves risks including but not limited to infection, misplaced pigment, poor colour retention and hyper- pigmentation

Yes

Touch up session is required within 4 to 6 weeks that will be $ only. After 6 weeks extra fees may apply .

Does

Does Not

Today's Appoinment Quotation $

I have been quoted for today's appointment that does include any touch up session

Yes

Touch-Up Session Fee $

I agree after 6 weeks extra cost may be applicable

Agree

Disagree

I have had the opportunity to ask questions relating to this treatment

Yes

I understand that cosmetic tattoo is an art form and not an exact science, and I acknowledge that NO guarantees have been made to me as to the result of this procedure. Some skin types will not accept or heal pigment in a consistent manner. Your skin and your after care of your procedure will determine your result. I also realise that Nikki can not predict how many visits it will take to complete my procedure

Yes

I will not hold Nikki Randhawa ( Harjeet Randhawa) in the event of any damage and that I shall not be entitled to take any action against her at Law and Equity for such treatment

Yes

I certify that I have read of have had read to me the contents of this form. I understand that risks and alternatives involved in the procedure and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize Nikki Randhawa, as my permanent cosmetic technician to perform the following procedure on my body:

Yes

Procedure

Client Name

Signature

Date

Photo Consent

Please note that we take photographs before and after every procedure for monitoring response to therapy

give my consent to Brow Mantra to use my photos for client records/social media/website/marketing purposes

PLEASE UPLOAD YOUR PHOTOS:You can upload multiple photos at a time

Signature

Date

MICROBLADING

CLIENT PERSONAL TRACKING FORM

Client Full Name

PRICING

Base Price

Touch up Price

Other

Calculated Total

$0

Total

Do you presently have or previously had any of the following: (Circle yes or no)

By clicking Yes, you understood that old tattooing can affect the final results. You also understood we have to work around the old tattooing and cannot re-create a new shape.

Possible risks, hazards or complications

The alternative to these possibilities is to use cosmetics and not undergo the cosmetic semi-permanent make up/ 3D Eyebrow Embroidery (Microblading) procedure.

Consent and release for procedures performed:

STATEMENT OF CONSENT AND RECITALS

Please read and initial all lines

Photo Consent

Please note that we take photographs before and after every procedure for monitoring response to therapy

MICROBLADING

CLIENT PERSONAL TRACKING FORM

PRICING

Calculated Total

$0

SERVICES

Do you presently have or previously had any of the following: (Circle yes or no)

By clicking Yes, you understood that old tattooing can affect the final results. You also understood we have to work around the old tattooing and cannot re-create a new shape.

Possible risks, hazards or complications

The alternative to these possibilities is to use cosmetics and not undergo the cosmetic semi-permanent make up/ 3D Eyebrow Embroidery (Microblading) procedure.

Consent and release for procedures performed:

STATEMENT OF CONSENT AND RECITALS

Please read and initial all lines

Photo Consent

Please note that we take photographs before and after every procedure for monitoring response to therapy

MICROBLADING

CLIENT PERSONAL TRACKING FORM

PRICING

Calculated Total

$0

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