Microblading Consent Form

Microblading Consent Form
Client Details
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com

COVID-19 DISCLAIMER

All clients will be required to have a secured mask on at all times.

If you have recently been tested for COVID-19 you can not be seen until your negative results are provided.

You are signature below indicates that you agree that you have not been to any high risk areas such as New York City, Brazil, China, Italy in the last 30 days.

Due to the increase in sanitation supplies neccesary there is a nominal PPE on all service prices until the need for them is cleared. This is soley the costs of providing this addtional protection.

WHAT WE ARE DOING TO PROTECT YOU:

We have a Hepa 13 Air Prufication System running in the treatment rooms.

We use a EPA Sanitizer on all contact surfaces between clients. We are staggering appointments and have a 2 hour gap between appointments. We are seeing a maximum of 3 clients per day.

We have sanitizer available for your use. We have eliminted paper forms. We offer contactless payments.

Please do not bring guests unless absolutely neccesary. Guests are limited to 1. Your guests will be asked to remain in the waiting area until your service is completed.

We reserve the right to refuse service to anyone we deem may be a risk to the saftey of our clients and staff.

I am signiging to indicate that I understand and agree to all of the above statments and that I am being truthful to the best of my knowledge.

Contact in case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number

CONSENT

I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and I consent to receiving the microblading procedure. I have been informed and it was explained to me the general nature of cosmetic tattooing as well as the specific procedure to be performed.

I have been informed of the possible risks and consequences of microblading and I understand that there might be complications and consequences associated with this procedure, such as: infection, scarring, or inconsistent color.

I understand that this cosmetic procedure is not fully permanent and might result to fading in time. I have likewise received and will strictly adhere to procedural instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my responsibility.

I have been advised to do a patch test to identify any allergic reaction to any medicine or anesthetics. Should I waive for the test, I release the technician from liability if I develop an allergic reaction to any of the procedure.

I acknowledge that some changes might not be corrected in case I undergo other laser hair removal, plastic surgery or other procedures.

I understand that photographs taken for comparison of the before and after procedure are part of the said procedure.

I accept full responsibility for the decision to have this microblading procedure done and any and all resulting complications.

I understand that more than two visits may be required for some skin types and while the need for more than 2 session is rare an proximate touch-ups will be $100 per visit.

I understand that microblading alone may not give me the look I am expecting and I will discuss this with my brow artist to ensure the best proecdure for my desired results is discussed.
Signature

Clear
Should be Empty:

	Yes	No
Currently Pregnant
Currently Breastfeeding
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)
Had undergone Botox treatment
Has or any family history of Diabetes
Has Hepatitis A B C D
Had Forehead/Brow Lift
Had Facelift Surgery
History of Alcoholism
Has a Heart Condition
Had a Brow Lash Tinting
Has Autoimmune disorder
Has Oily Skin
Has, had, or any family history of having Cancer
Had undergone Chemotherapy/ Radiation
Taking or have taken acne treatments in the past 3 months
Had a Tan treatment
Difficulty numbing with dental work
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc
Allergic reaction to any medications
Allergies to metals, food, etc,
Any diseases other than listed here
Do you use facial care treatments?