PMU

Consent Form for Semi Permanent Procedure

Name

Last Name

Phone Number

Birth Date

Month

Day

Year

Adress

Emergency Contact

(name and phone number)

What is your Instagram

What is your TikTok

Specify here:

I declare that I have read the FAQ’s, as per pre-booking instructions to prepare for my appointment, and have read “Am I a good candidate?” and “pre- and post- procedure instructions”.

Yes

I declare that I have read the FAQ’s, as per pre-booking instructions to prepare for my appointment, and have read “Am I a good candidate?” and “pre- and post- procedure instructions” and will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. Please refer to FAQ’s on the website. https://www.hausofdebi.com/faq-and-cancelation-policy

Medical Questionnaire

I understand that it is important to answer each of the following questions honestly and not withhold medical information, as failure to do so may be detrimental to my health and safety during the treatment. There are a number of risks from withholding information which include, an increased risk of infection, bleeding, compromising the end results and risking further complications, poor healing or scarring. I understand it is my responsibility to update any changes in my medical history to the Artist before every appointment.

If you answered YES to any of the above, please provide a brief explanation below:

Yes

If "Other", specify here:

I understand that if I answered “yes” to any of the above statements then I might have excessive bleeding and therefore results won’t be optimal and in most cases it will require more than one touch up.

Yes

I understand that it is my responsibility to advise the technician verbally of any concerns I may have before they begin the procedure, even though I may have written it down on the form.

Yes

There is a possibility of an allergic reaction to pigments. While a patch test is recommended, it doesn't guarantee no reaction. By waiving the patch test, I release the technician from liability for any allergic reaction.

I waive the patch test

I’ve had the patch test

I am a client of DebiBrows and I have Re-done the patch test or have been in the studio within the last 6 months

I am a client of DebiBrows and I waive the patch test

Please note: reactions may occur even after a patch test.

Disclosure & Release Form For Implantation Of Pigment

CLIENT DISCLOSURE By ticking off each one it indicates that I have read and understand completely.

Yes

No warranty or guarantee has been made to me as a result of this semi-permanent makeup and that the final result cannot be guaranteed. I realize that there is potential for discomfort during the procedure and during the healing process as well as a possibility of bleeding, swelling. I have been informed that all semi permanent makeup technique results will gradually fade for various reasons.

Yes

I understand that the healing process is different for every person. Pigment loss or color change normally happens in most of the cases during the first week. Please refer to FAQ’s on the website. I understand I must book the touch up session 4 to 6 weeks after the initial session (when skin is completely healed) for optimal results. In some cases, additional touch up sessions may be required and fees for additional touch up sessions will apply.

Yes

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, scarring, inconsistent color, and spreading, fanning or fading of pigments.

Yes

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 permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure.

Here at Haus of Debi we pride ourselves on keeping our guests health and safety our number one priority. With this ideal in mind, we want to bring a safety regulation to your attention.

Professional semi permanent tint manufacturers recommend a patch test to be performed 24 hours prior to any semi permanent treatment, where the product is applied directly to the skin. There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction.

I waive the patch test

I’ve had the patch test

I am a client of Haus of Debi / DebiBrows and have been in the studio within the last 6 months

Date of patch test or date of last treatment:

As a client of Haus of Debi, once you’ve had a patch test, it is then valid for as long as you continue to use our services at our studio or 6 months after your last treatment.

Yes

It is your responsibility to make sure you schedule your patch testing as required and will not hold Haus of Debi responsible for your negligence.

I understand semi permanent techniques may NOT take well on top of old permanent makeup tattoos.

Yes

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 cosmetics. I acknowledge some of these potential adverse changes may not be correctable.

Client Acknowledgment And Responsibility To Inform The Technician

Please read and tick to agree the statements below:

Yes

CLIENT further agrees to indemnify and hold harmless HAUSOFDEBI.COM, its governing officers, consultants, employees, agents, and subsidiaries, from any claim of liability, losses, damages, or any expenses whatsoever as a result of any claims, demands, damages, costs or judgments including, but not limited to, claims based on negligence against it, that may arise in connection with the services performed by an independently contracted technician.

This Agreement is intended to be an addendum to any previous conditions, releases, or hold harmless agreements, in written form, verbal, or manually communicated between HAUSOFDEBI.COM and its client in connection with semi-permanent makeup procedures.

I understand that taking Before and After pictures is a condition of such procedures.

Yes

I hereby forever release and discharge HAUSOFDEBI.COM from any and all claims, action and demands arising out of use of said photographs for website and social media outlets.

I release HAUSOFDEBI.COM and its representatives and subsidiaries of all claims for injury, seen or unseen, that may occur as a result of this procedure.

Yes

I fully understand the questions, terms, and conditions of this Disclosure and Release Agreement, and all have been explained to me in my native language.

Yes

I accept to waive all my rights for any claim against HAUSOFDEBI.COM for any reasons may involve whatsoever.

Personal Data protection: we inform you that the information contained in this document is included in the information systems of Haus of Debi.

Yes

You can exercise the rights of access, rectification, opposition, limitation, portability or cancellation, to the address hola@debibrows.com. You can access more information through the link: https://www.hausofdebi.com/private-policy

Date:

Firma

Signature field is empty.

I certify that this Disclosure, Release Agreement, Client Acknowledgment & Responsibility to Inform was completed by me and that all entries in it and information are true and complete to the best of my knowledge. I ACCEPT FULL RESPONSIBILITY FOR THE DECISION TO HAVE THIS COSMETIC TATTOO WORK DONE.

If client is a minor, under 18 years of age, legal guardian must put FULL NAME, IDENTIFICATION DETAILS in this space and SIGN BELOW:

Legal Guardian Signature:

Signature field is empty.

For technician use only below:

Color, needle , lot number: