DISCLOSURE & RELEASE FORM

CONTACT & BILLING INFORMATION

HAIR SPARKLES: YOU MUST BE 12 YEARS OR OLDER. NO CONSENT FORM NECESSARY FOR THIS SERVICE.

First Name *

Last Name *

Age *

Street Address *

City *

State *

Zip Code *

Phone Number (no dashes/spaces) *

Email *

Emergency Contact Name *

Relationship to Client *

Phone Number (no dashes/spaces) *

Email

LATE FEE, LATE CANCELLATION, & NO-SHOW POLICY

In order to schedule with us, we must have a valid credit card on file. This card will be securely stored in your account, and will only be charged in the event of a late-cancellation or no-show, and for deposits. *

I Agree

Credit Card (no dashes/spaces) *

CVC *

Expiration *

Billing Zipcode *

IF THE CLIENT IS A MINOR

IF THE CLIENT IS A MINOR (10 TO 17 YEARS OF AGE)

Clients must be at least 10 years of age to receive any hair removal/waxing services. Parental consent is required for clients between 10 and 17 years of age. If under 18, I guarantee that I am the client’s parent or legal guardian, and I am signing this release on behalf of myself and the client.

Are you under 18 years of age? *

I am a minor receiving services with parental consent.

I am a minor seeking services without parental consent.

WE APOLOGIZE, BUT WE ARE UNABLE TO PERFORM ANY SERVICES ON MINORS WITHOUT PROOF OF PARENTAL CONSENT. PLEASE NOTIFY YOUR TECHNICIAN.

Please upload a photo of your parent's Driver's License: *

Parent/Guardian Signature *

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COVID-19 PROTOCOL

Clients must adhere to the following - When arriving to your appointment, follow the posted instructions:

Please complete your consent form prior to entering the shop.
Clients may be required to wear a face-covering during their service, at their technician's request.

Do not enter our facility, and notify us immediately if you believe that you, or someone you've come into contact with in the last 10 days, have tested positive or believe to be a positive COVID-19 case.

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that by entering Boulder Brows I may be exposed to or infected by COVID-19 and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death (herein after “Risks”). I understand that the risk of becoming exposed to or infected by COVID-19, may result from the actions, omissions, or negligence of myself or others, including, but not limited to, Boulder Brows employees and others. I voluntarily agree to assume all the Risks and accept sole responsibility for any injury to myself, including, but not limited to, illness, personal injury, disability, death, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my admission to this facility (“Claims”). On behalf of myself and my employer, my family members, agents, successors, and assigns, I hereby release, covenant not to sue, discharge, and hold harmless Boulder Brows, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims related to the possibility of COVID-19 infections based on the actions, omissions, or negligence of Boulder Brows, its employees, and others, whether a COVID019 infections occurs before, during or after my admission to your facility. *

I Agree

PREFERRED METHODS OF COMMUNICATION

I understand that if I need to get in touch with Boulder Brows for any reason, I will reach out via one of the following ways: emailing info@boulderbrows.com, or texting/calling us at 833-239-6669. Any other method of communication is not appropriate and will not receive a response. We do not have a receptionist and thus are not always available to take calls during the day. Emailing, or texting us is preferred for requesting a call back, and for last-minute scheduling/rescheduling requests. *

I understand and will adhere to this policy.

CLIENT ACKNOWLEDGEMENT AND DISCLOSURE

What services will you be receiving today? *

Beauty Service (Non-Tattoo)

Cosmetic Tattoo

Tattoo Removal

I consent to the following beauty services: *

Brow Tinting

Brow Waxing/Tweezing

Facial Waxing (Non-Eyebrow)

I consent to the following Permanent Makeup/Removal services: *

Cosmetic Eyebrow Tattoo

Permanent Eyeliner

Beauty Mark(s)

Saline Tattoo Removal

Style Preference *

A copy of your ID/Driver's License is required by law to receive any cosmetic tattoo services. Please upload a photo to store on file. *

SERVICE DESCRIPTION

Eyebrows are your most important feature, providing a frame for your face. Shaping your brows will accent your natural size and shape through brow tinting, careful trimming, tweezing, and other hair removal methods, and/or makeup application to create balance, symmetry and harmony.

POTENTIAL RISKS

Allergic reaction, breakouts, skin irritation, bleeding, and undesirable results. Please note that this treatment is completely different from an eyebrow permanent makeup procedure. We are only able to work with existing hair and cannot create the same changes that are limited exclusively to said permanent makeup procedure.

Please read the statements below, checking each box, to indicate that you understand the following completely: *

SERVICE DESCRIPTION

Waxing is the removal of unwanted hair from a designated area by applying a heated wax layer to the skin, and removing both the wax and hair simultaneously.

POTENTIAL RISKS

Allergic reaction, breakouts, skin irritation, bleeding, and undesirable results can occur. Although every precaution will be made to ensure your safety and well-being before, during and after your service, please be aware of the possible risks below.

HEALTH ACKNOWLEDGEMENT

I understand that I should not have this service if I have any current outbreaks/rashes/fever blisters/herpes sores, if the area is currently compromised (i.e. sunburn, recently tanned, professional exfoliation), or if I am currently using (or have recently used) any of the following products or have recently had any of the following procedures.

Please read the statements below, checking each box, to indicate that you understand the following completely: *

That no warranty or guarantee has been made to me as a result of this procedure, and that the final result cannot be guaranteed.

That there may be risks and hazards related to the performance of this procedure planned for me.

I realize that there is potential for discomfort during the procedure and during the healing process.

There is a possibility of bleeding, swelling, and allergic reactions to the dye.

That tattooing is considered permanent, however, it may fade with time.

That a tattoo can only be removed with a surgical procedure, and that any effective removal may leave permanent scarring or disfigurement.

That misplacement of the dye can occur, under rare circumstances, requiring excision of the misplaced dye. In rare cases, there may be permanent loss of eyelashes after an eyeliner procedure.

WHAT IS SALINE TATTOO REMOVAL?

The Saline Tattoo Removal Method removes/lightens unwanted pigment through a series of sessions (3+).

The skin of the treatment site will be opened and the lightening solution applied. This solution draws unwanted pigment to the surface of the skin and collects into dark, visible scabs. The pigment is removed with the scabs when they fall off naturally. This process keeps hair follicles intact, allowing your eyebrow hair to continue to grow, as well as maintaining healthy skin for us to tattoo in the future. This method cannot remove pigment entirely, but it can lighten the existing PMU significantly for optimal PMU procedures in the future.

Which of the following best describes your skin type? *

FOR SKIN TYPES IV AND V: I understand that I am at a higher risk for hyper/hypo-pigmentation than other skin types. I agree to the risk involved. *

I Understand & Agree

I understand that lightening tattoo pigment is difficult, if even possible. As a result I will not hold my technician or Boulder Brows responsible for any resultant failure to lighten the unwanted pigment. *

I Understand & Agree

MEDICAL HISTORY

Allergies to any of the following: dyes/tints, disinfectants, soaps, other - *

Yes

No

Allergies to any of the following: dyes/tints, disinfectants, soaps, other -

Current Medications & Vitamins/Supplements: (please list any and all)

Current List of Skincare/Homecare & Makeup/Cosmetic Products:

MEDICAL HISTORY

SKIN HISTORY *

Other Skin Disorder - Please specify *

MEDICAL HISTORY

SKIN HISTORY *

Auto Immune Disease - Please specify *

Other Skin Disorder - Please specify *

If you have sensitive skin and/or any allergies you have concerns about regarding this procedure, would you be interested in coming in prior to your appointment for a Patch-Test? *

Yes

No

Pre-Existing Work? Clients that are new to Boulder Brows are required to select the standard full-price initial session. Even if you have pre-existing work from another artist that you are looking to have touched-up/refreshed, you are still new to us and must schedule as a new client. Boulder Brows does specialize in corrective work and requires those potential clients to send us photos of your existing work via email prior to scheduling. Our master artist will review these photos and determines eligibility on a case by case basis. If the existing work is too dark and saturated, Tattoo Removal may be recommended to lighten it prior to booking a PMU appointment with us. *

I understand

Upload Images of Pre-Existing Work * 🛈

I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. *

I Agree

As a client, you have a responsibility to inform the technician of all possible concerns. Please read the statements below, checking each box, to indicate that you understand the following completely: *

I understand that I must inform my technician of all medications being taken by me, even though I have written it on the General Medical History and Confidential Medical History forms. For example, pain control medication such as aspirin may cause the blood to thin, and excessive bleeding may occur.

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

I will not consume any caffeine or alcohol 12 hours prior to my appointment. I will not consume any fish oil, anticoagulants or blood thinning drugs 4 days prior to my appointment.

I am, and will remain, free from drug and alcohol use or any other substances that would impair my ability to consent to this service.

I am not pregnant / will not be pregnant at the time of my service.

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

Are We The Right Fit? Please keep in mind that our Permanent Makeup Services are an artistic collaboration between the artist and the client. Our artists must feel confident that they are the right fit based on a number of factors: the desired aesthetic, the necessity of collaboration between the artist and client, and the energy going into the procedure. Please be aware that we may not be the best fit for every client. If the artist does not feel that they are the best fit to perform your service, they will inform you and will discuss other options. *

I understand that there is a possibility I will not be tattooed the day of my appointment.

PRE-APPOINTMENT PROTOCOL

NO CAFFEINE or alcohol 24 hours prior to your appointment - that includes your morning coffee the day of (including decaf). No fish oil, anticoagulants or blood thinning drugs 4 days prior to your appointment. Your appointment will be rescheduled for failure to follow the pre-appointment preparation protocol, and your deposit will be forfeited. Beautiful results cannot be achieved if you arrive in a compromised state, and it will ultimately cost you more time and money having to book more sessions to get the results you want. If we learn that you have failed to follow any part of your pre-procedure protocol, you will be rescheduled and you will lose your deposit. You will have to reschedule at a later date, and another deposit will be required to do so. *

I understand and agree to follow the Pre-Appointment Protocol prior to my procedure

SCHEDULING YOUR FOLLOW UP

Part 2 is included in the total cost of the service. If you have no intention of coming back for your follow-up session, then we do not recommend booking the initial session - it's a two-part process. Please be advised that if you have to cancel Part 2 or a touchup for any reason, you may be assessed a higher price if you are unable to secure a new appointment within 8 weeks of your initial session. We cannot guarantee availability if you need to reschedule, but will do our best to accommodate you in a timely manner. The Part 2 Session is a "perfecting" appointment, designed to make any adjustments needed from the first session. It will no longer be included in the original pricing if it is scheduled outside of the 8-week window, as this is now considered a Refresh. *

I understand that Part 2 is necessary and I will schedule my followup 5-8 weeks from my initial session.

HOMECARE COMMITMENT

Avoid using oils or products that contain oils directly on the treated area following the service. This can cause the tinting results to fade more quickly. If you decide to wear makeup on the treated area, the removal of that makeup can also cause the color to fade more quickly. *

I have read and understand the post-treatment home care instructions.

I agree that I will follow recommendations by my technician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of allowing the scabs to fall off naturally, applying Aquaphor as advised by my technician, and avoiding excessive sweating, sun/tanning booths, and extreme weather conditions. In the event that I may have additional questions or concerns regarding my treatment or suggested post-treatment care, I will consult Boulder Brows immediately by phone or email. *

I have read and understand the aftercare involved for this procedure and agree to follow the recommended aftercare regimen.

I agree that I will follow recommendations by my technician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of allowing the scabs to fall off naturally, applying Vitamin E Oil regularly once they do, and avoiding excessive sweating, sun/tanning booths, and extreme weather conditions. In the event that I may have additional questions or concerns regarding my treatment or suggested post-treatment care, I will consult Boulder Brows immediately. *

I have read and understand the aftercare involved for this procedure and agree to follow the recommended aftercare regimen.

LIABILITY RELEASE

I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I will address any questions/concerns I have with my technician prior to my service. I do not hold Boulder Brows responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today. *

I Agree

I have read the above information and checked the box for each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my technician. I give permission to my technician to perform this procedure and will hold her and Boulder Brows harmless from any liability that may result from this treatment. I understand my technician will take every precaution to minimize or eliminate negative reactions as much as possible. This procedure has been known to cause scabbing, which may not appear until a day or two following my treatment. I do understand that, very rarely, skin damage can occur. I have given an accurate account of any over-the-counter or prescription medications that I use regularly. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, chemical peels or other skin treatments that I have not disclosed to my technician. I am not ingesting or using topically any other over-the-counter product or prescription medication/agent that has not been disclosed to my technician. *

I Agree

PHOTOGRAPHY & PUBLICITY CONSENT AND RELEASE

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my technician. *

I Agree

I consent to the sharing of any photographs taken today for use on social media for the purpose of advertising for Boulder Brows LLC, and for it’s agents/employees after the termination of their employment for future advertising purposes. *

I Agree

I Disagree

CLIENT ACKNOWLEDGEMENT & AGREEMENT TO BUSINESS POLICY

By checking the boxes below, you agree to the following: * 🛈

I have read and understand ALL of Boulder Brows' Business Policies.

I understand Boulder Brows' No Children, No Guest, & No Pet Policies and will arrive to my appointment alone.

I have read and understand Boulder Brows' No Refund on Services Rendered Policy. I understand that my deposit is non-refundable.

I understand that if I do not notify Boulder Brows ahead of time that I will not be able to make it to my appointment via one of their preferred methods of communication, I will lose my deposit and will be charged the remaining balance.

I understand that results are not guaranteed for this service.

By checking the boxes below, you agree to the following: *

BY SIGNING BELOW, YOU CERTIFY THAT ALL OF THE INFORMATION YOU'VE PROVIDED IS ACCURATE TO THE BEST OF YOUR KNOWLEDGE, AND THAT YOU CONSENT TO RECEIVING THE SERVICE(S) YOU HAVE REQUESTED. *

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