SERVICES
OUR WORKS
AFTER-CARE
FAQ
Contact Us
SERVICES
OUR WORKS
AFTER-CARE
FAQ
Contact Us
LusisBrow Customer Registration
Step 1 of 3
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Name
*
First
Last
Date of Birth
*
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Phone
Email
How did you hear about us?
*
Instagram
Google Search
Facebook
Friend
Other
Consents to Application of Semi-Permanent Makeup Procedure
Do you have any known allergic reactions or sensitivities to any topical or local anesthetics?
*
YES
NO
Do you have any allergies (i.e. Polysprorin, Bacitracin, Neosporin, Latex, etc)?
*
YES
NO
Are you allergic to lidocaine or any other numbing agents?
*
YES
NO
Are you currently pregnant or breast-feeding?
*
YES
NO
Do you bruise easily?
*
YES
NO
Do you have any heart conditions or high blood pressure?
*
YES
NO
Do you have or do you think it is possible that you have any blood borne communicable disease such as HIV or Hepatitis?
*
YES
NO
Do you have any serious medical conditions?
*
YES
NO
Does your skin swell easily?
*
YES
NO
Do you have diabetes, currently on any form of immunosuppressant therapy or any condition that may delay healing?
*
YES
NO
Do you suffer from any form of Hyperpigmentary skin condition?
*
YES
NO
Do you have any known personal history or family history of Methemoglobinemia?
*
YES
NO
Have you ever had a Herpes Simplex Type 1 infection?
*
YES
NO
Do you use Retin A or Hydroxyl (Glycolic) Acid preparations?
*
YES
NO
Are you prone to Keloid scarring, hypertrophic scarring or any other form of excessive scarring conditions?
*
YES
NO
Do you have a bleeding disorder or take blood thinners?
*
YES
NO
Are you allergic or sensitive to any metals?
*
YES
NO
Have you had any form of cosmetic or surgical procedure, Radiotherapy or Chemotherapy at any time within the last 6 months?(botox, injections, laser therapies, facelifts, etc)
*
YES
NO
Do you have any chronic or acute eye disease?
*
YES
NO
The UNDERSIGNED acknowledges that Lusis Brow has explained the nature of procedure, including the risks and dangers inherent therein. I HEREBY CONSENT to Black Line Brow performing cosmetic tattoo treatment and its procedure on me and in consideration of her doing so, I hereby release and forever discharge Lusis Brow from all demands, damages, actions or causes of action arising out of the performance of the said treatment procedurs, which I, may heirs, executiors, administrators or assign can, shall or many have. No refund on any treatmen. I accept the above colour, design, and payment terms in this contract.
I hereby consent to LusisBrow taking photographs of the undersigned both before and after any procedures being undertaken by LusisBrow at the request of the undersigned. It is further acknowledged that the undersigned authorizes LusisBrow to use such photographs in compiling albums of its various clients for the purpose of showing potential clients the procedures completed. This release shall be deemed to have been made and shall be constructed in accordance with the Laws of the Province of Ontario.
*
YES
