Consent & Procedure Form

MolliJo Makeup Studios, LLC dba.  MolliJo Aesthetics

1. I represent and warrant to MolliJo Aesthetics that the above information is true and correct.  

2. I agree that I have undergone an extensive consultation with a MolliJo Aesthetics technician, in which all the risks of the procedure have been explained to me and that all of my questions were then answered.  

3. I agree that I have filled out a Client Intake/Medical History form and represent and warrant that all the information I gave is true and correct. 

4. I understand that undisclosed information, especially regarding medications, allergies, or medical conditions, can lead to adverse effects of the procedure performed; causing, but not limited to, the possibility of allergic reactions or undesired healed procedure results.  

5. I agree that I shall follow the post-procedure instructions that I  have been given by MolliJo Aesthetics, and understand that by not following these instructions completely could cause undesired procedure results or premature fading of the treatment areas.

6. I understand that if my skin color is darker toned, the color will not appear as bright as it does on lighter toned skin. I also understand  that the color will fade as the months and years go by. Color fading is different for each client seen, as each client’s body processes the pigments differently. Healed color results and longevity of the procedure can not be guaranteed, only estimated.

7. MolliJo Aesthetics cannot guarantee the final pigment color in the skin. Therefore, clients take full responsibility for changes of color after the procedure has been completed. Should the client desire any color changes after the procedure has been completed, there will be an additional charge based on a prevailing hourly or session rate.

8. I agree and understand that if there are any hyperpigmentation spots on the area to be worked on, they may become more noticeable.

9. I have been informed and understand that after any medical  micropigmentation procedure I cannot proceed in future laser treatments on the area, as the pigment will have a high risk of turning black and will become irreversible to correct. If I fail to abide by this, I understand that MolliJo Aesthetics is in no way at fault.  

10. I have been informed that if my racial origin, or any part thereof, is Black, Indian, or any other race other than what is commonly known as Caucasian or “White”, the procedure color may be affected, or there may be a possibility of hyperpigmentation. I accept that this may happen and proceed with this knowledge.

11. I agree to the taking of before and after photographs of the procedure, which may be used for advertising purposes. Close up or cropped photos of the procedure area(s) can be taken to conceal the client's identity upon request. 

12. I agree that if I suffer from hyperpigmentation or am prone to hyperpigmentation, a patch test will be required. I understand that there is a patch test fee, and that it is non-­refundable. I will take full responsibility of the final result.

13. I understand that with paramedical micropigmentation I might not see results after the first session, and I will need to continue with my sessions to see an improvement in the texture and color of the area being treated. Number of required sessions can not be guaranteed, only estimated.

14. I understand that paramedical micropigmentation is an art, not an exact science. Therefore, there are no guarantees that the area being treated will be camouflaged, disappear, or blend 100% with the client's skin. I understand that Paramedical Micropigmentation procedures help to reduce the visibility and appearance of the area(s) being treated, and do not guaranteed "perfection" due to the skin's ever-changing undertones.

15. I understand that with cosmetic pigmentation, 2 sessions are always required for a final result in the procedure. 2nd sessions must be booked 6-12 weeks following the initial session, to be included in initial service pricing. I am made aware that in some circumstances an additional touch-up session may be needed in the procedure area; this can be due to mature skin, thick or stubborn skin, scar tissue, previous tattooing on the area, certain medications taken, autoimmune diseases, and some medical conditions. I understand that 2nd sessions/additional touch-up sessions booked after 12 weeks are charged at the prevailing rate to cover MolliJo Aesthetics’ equipment and tray setup fees.

16. I understand that all of MolliJo Aesthetics services and procedures are non-refundable, under all circumstances, due to the nature of the procedures performed and services rendered. All of MolliJo Aesthetics procedure rates are individually calculated by material costs, specialized products, tray setup fees, technician time, technician training, licensure, and industry experience. By agreeing to the procedure or service, and making your purchase or transaction, you are in agreement to MolliJo Aesthetics refund policies.  

17. I understand that a procedure or service rate quote that was given to me during a virtual or in-­salon consultation by a MolliJo Aesthetics technician will be valid for up to 12 months.  

18. I understand that MolliJo Aesthetics' procedure and service rates are subject to change at any given time without notice.  

19. Being of sound mind and body, I hereby release MolliJo Aesthetics from all responsibilities. I accept and take all responsibility of myself and any consequences that might stem from my decision to have any paramedical or cosmetic micropigmentation implantation procedure done by MolliJo Aesthetics, its technicians, or its representatives.

20. I agree not to sue MolliJo Aesthetics or any and all individual technicians or representatives of MolliJo Aesthetics in connection with any damages, claims, demands, rights and causes of action, of whatever kind of nature, based upon injuries or property damage, to, or myself or any other persons arising from my decision to have micropigmentation implantation done by MolliJo Aesthetics or its technicians or representatives.

21. I agree for myself, my heirs, assigns and legal representatives to hold MolliJo Aesthetics harmless from all damages, actions, causes of actions, claim judgments, costs of litigation, attorney fees and all other costs and expenses which might arise from my decision to have any micropigmentation implantation procedures done by MolliJo Aesthetics or its technicians or representatives. I agree that these waivers also pertain to and are designed to protect any and all establishments where MolliJo Aesthetics may conduct business.

 

I have read and understand each of the above paragraphs and hereby sign: