Pre-Treatment Advice and Procedures

Ezbrows Studio Emily Lee (510)-703-1512 | [email protected] 2298 E.14St San Leandro, CA 94577

1) Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear “crusty” for up to one week.

2) Please wear your normal make-up to the procedure. If you are having lips or brows done, please bring your favorite pencils.

3) If unwanted hair is normally removed in the area to be treated, i.e.; tweezing or waxing, the hair removal should be done at least 24 hours prior to your procedure. Electrolysis should not be done within five days of the procedure. Do not resume any method of hair removal for a week after the procedure.

4) If eyelashes or eyebrows are normally dyed, do not have that procedure done within 48 hours of this procedure. Wait one week after the eyebrow or eyeliner procedure before dying lashes or brows.

5) If you wear contact lenses and are having the eyeliner done, do not wear your lenses to your appointment and do not replace them until the day after the procedure.

6) If you are having the eyeliner procedure done, as a safety precaution, in case of watering or swelling, we recommend that you have someone available, or accompany you, who could drive you home if you so decide, or if it is necessary.

7) If you are having lip liner done and have had previous problems with cold sores, fever blisters, or mouth ulcers, the procedure is likely to re-activate the problem. Your Intradermal Cosmetic Technician can make recommendations to help prevent or minimize the outbreak.

8) We recommend allergy testing of pigment before the planned procedure.

9) Do not use aspirin or ibuprofen for 7 days prior to your procedure.

10) This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow, Microblading, semi-permanent makeup application. If you have any questions, please don’t hesitate to ask. Ezbrows Studio Emily Lee (510)-703-1512 2298 E.14St San Leandro, CA 94577 11) This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent.

12) 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.

13) Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is normal and even advised for a Touch-Up after healing is completed.

14) Initially the color will appear more vibrant or dark compared to the end result. Usually within 5-7 days the color will fade 20-30%, 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.

Please read through these forms to be sure you are a candidate for permanent makeup.

In order to save time during your appointment, please print and sign these forms to bring with you to your appointment.

We look forward to working with you. If you have any questions, please call or make notes so we can discuss them with you when you arrive for your appointment.

Disclosure and Consent for Tattoo and Dermal Procedures

I, , as a client have requested that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure.

You have described the recommended procedure to be used as Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of skin. Micro pigment Implantation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.

I voluntarily request as my intradermal cosmetic technician, Emily Lee and such association and technical assistance as she may deem necessary to perform on my body the following procedure (select one):

UPPER EYELID LOWER EYELID LOWER MUCOSAL EYELID EYEBROW FULL LIP COLOR LIP LINER

AREOLAS SCAR CAMOUFLAGE

STRETCH MARKS OTHER:

Please Initial:

I hereby authorize Emily Lee to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.

I hereby authorize Emily Lee to take photographs of the work performed both before and after treatment to be maintained only in !le.

I have informed Emily Lee that I am in good health and not under the care of any physician.

I am currently under the care of a physician and I am being treated for the following condition(s): Ezbrows Studio Emily Lee (510)-703-1512 | [email protected] 2298 E.14St San Leandro, CA 94577

Physician’s Name: Phone Number:

Address: City/State: Zip:

Please Initial:

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure.

I have been told that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results.

I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment; however, spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to (select one):

RECEIVE WAIVE a spot test prior to application and I agree to release Emily Lee assistants and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments.

I have been told that allergic reactions to pigment are very rare, however, they can and do occur and when they occur they can be serious and especially difficult and very troublesome to treat.

I have been informed that this procedure involves latex gloves and antibiotics and that there is a possibility of an allergic reaction to these substances. Ezbrows Studio Emily Lee (510)-703-1512 | [email protected] 2298 E.14St San Leandro, CA 94577 Disclosure and Consent for Tattoo and Dermal Procedures (continued)…

I have been told that this procedure will involve pain and discomfort.

I understand the markings are permanent and that there is a possibility of hyper pigmentation resulting from a procedure, especially in individuals prone to hyper pigmentation from a scar or other injury.

I understand that implanted pigment color can slightly change or fade over time 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 understand that the tattoo ink and pigments used in this procedure are not FDA approved.

Other risks involved with the procedure may include, but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction(s) to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.

I have been informed of the signs and symptoms of an infection and allergic reaction.

I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me.

I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.

I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify Emily Lee and I further agree that any controversy or claim Ezbrows Studio Emily Lee (510)-703-1512 | [email protected] 2298 E.14St San Leandro, CA 94577

arising out of or relating to this consent and/or any signed contract between myself and Emily Lee or the breach thereof, shall be settled by arbitration in the state of California in accordance with the Rules of the American Arbitration Association and judgment of the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Emily Lee, a health care practitioner, California Department of Health, Drugs and Medical Devices Division.

I certify this form has been fully explained to me and I have read it or it has been read to me. I understand its contents.

I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its contents.

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

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. Touch-ups must be completed within 60 days of initial procedure.

I have been quoted the cost of today’s appointment, and the cost of the touch-up. Touch-ups must be completed within 60 days of initial procedure to be considered a touch-up price.

Signature: Date:

Medical History Form

Today’s Date: Birth date:

Home Address:

No. & Street City State Zip Work Address:

No. & Street City State Zip Home Phone: Work Phone:

Employer: Occupation:

Are you now or have you been under the care of a physician within the last two years?

If yes, please provide Physician’s Name, address and phone number.

Person to contact in an emergency Name: Phone:

Address:

No. & Street City State Zip List all medications you are currently taking, including Retin A, Glycolic Acid and Accutane: Ezbrows Studio Emily Lee (510)-703-1512 | [email protected] 2298 E.14St San Leandro, CA 94577

List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams):

Have you recently undergone a skin peel?

What products do you use for skin care?

Do you have or have you had any of the following conditions (check all that apply):

Abnormal Heart Condition Eye Surgery or Injury

Cold Sores Blepharoplasty (eyelid surgery)

Herpes Simplex Visual Disturbances

Hemophilia Cancer

High or Low Blood Pressure Tumors/Growths/Cysts

Prolonged Bleeding Chemotherapy/Radiation

Circulatory Problems Are you pregnant?

Epilepsy Hepatitis

Diabetes Do you wear contact lenses?

Fainting Spells/Dizziness Do you use tobacco products?

Cataracts Glaucoma

Are you using any eye drops or other Have you ever experienced hyper- ocular medications? pigmentation from an injury? “Dry Eye” Are you currently taking aspirin or ibuprofen?

Corneal Abrasions

When was your last eye exam? Examining Physician:

Signature: Date: Ezbrows Studio Emily Lee (510)-703-1512 | [email protected] 2298 E.14St San Leandro, CA 94577 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. Signs and symptoms of an infection include swelling, pain, and leakage of pus at the procedural site, as well as general fever. If you experience these symptoms, especially a high fever several days post-procedure, please seek medical attention. 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 our 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.

Allergic Reaction: Substances will be used during the procedure that may cause an allergic reaction. Please inform me of any known allergies, especially to Latex, Antibiotics, or Anesthetics. These. Anesthetics being used may include Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream/liquid. Latex gloves will be used during the procedure.

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: