CLIENT GENERAL CONSENT + MEDICAL FORM

CLIENT CONSENT/MEDICAL FORM

MICROBLADING + PMU SERVICES
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 make up application. If you have questions, please do not hesitate to ask.
- This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing.
- 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.
- Generally, the results are excellent. It is usual to expect a touch-up after the healing is completed.
- Initially the color will appear much more vibrant or darker compared to the end result. Usually within 14-28 days, the color will fade 15 - 20%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years.
- Please review the risks, hazards and complications listed below. Not all clients will have the same healing process or results. We are not liable if your skin does not retain the pigment due to skin type, or any factors outside of our procedural processes.
POSSIBLE RISKS, HAZARDS OR COMPLICATIONS
Pain: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.

Infection: Although rare, there is a risk of Infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “Post Treatment” 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 are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness.

Excessive Swelling: Some people swell more than others. The swelling typically disappears within 2 - 4days. Some people don’t swell at all.

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 a MRI machine. You must inform your artist of any tattoos or permanent cosmetics.
Signature *

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LIST OF ALL CURRENT MEDICATIONS

	Mg. or Mcg.	How Many Per Day?	Reason For Prescription
Name of Drug
Name of Drug
Name of Drug
Name of Drug

LIST OF ALL MEDICATIONS YOU TOOK IN THE LAST SIX (6) MONTHS THAT YOU ARE NO LONGER TAKING:

	Mg. or Mcg.	How Many Per Day?	Reason For Prescription
Name of Drug
Name of Drug
Name of Drug

Do you have any allergies to medications? *
PLEASE LIST ANY ALLERGIES HERE. IF NONE, WRITE NONE.
The client consents initials* or waives initials* their right to an allergy test prior to the permanent tattoo procedure to determine allergic or other reactions to the pigments being used by the Practitioner.
CLIENT SIGNATURE (YOU MUST SIGN THIS!) *

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Date *

Month Day Year
Date

INFORMED CONSENT TO PROCEDURE

(please initial)
Initial*   I absolutely understand and accept that such a procedure is a process, often requiring multiple applications of color to achieve desirable results and the 100% success cannot be guaranteed.

Initial* I have received, reviewed and understand the pre-procedural instructions as given to me and agree to follow them.

Initial*Depending on the procedure(s), which I select, I accept responsibility for determining the shape, and position of eyebrows, eyeliners, lipliner and/or full lip color.

Initial*   I understand that the color selection and color results in all procedures are not an exact science.

Initial*   I understand that positioning of my procedures can be affected if I have elected or wish to elect cosmetic surgery, Botox or Restylane and I assume this responsibility.

Initial*   I am aware that if I am to receive an MRI after the procedure, I must tell the Radiologist that I have iron oxide permanent cosmetics.

Initial * If I am a lens wearer, I realize that I must keep my lenses out the day of an eyeliner procedure.

Initial*   I understand that this procedure will fade and this fading can alter the original pigment color and that this determines that it is a time for a touch-up visit.

Initial*   I realize this is an elective cosmetic procedure and is not medically necessary.

Initial*   It has been explained to me that the following possibilities may occur: Minor and temporary bleeding, bruising, redness or other discoloration; swelling; fever blisters on the lip area following lip procedures and/or fading or loss of pigment.

Initial*   I understand that many lasers & IPL’s (Intense Pulse Lights) including those used for hair removal, anti-aging, Photo Facials, removal of lines may or will turn permanent makeup dark or even black.

I agree to inform my esthetician or anyone operating such that I have permanent make up.

Initial*I give my consent to Arch Angels NYC + NJ to confer with my physicians for medical information required for the safety of my procedures.

Initial* I agree to accompany my practitioner to the emergency room in the event they were to be accidentally stuck with my needle and take a blood test for their safety & disclose all test results to my practitioner.

Initial* I am aware that if an infection occurs after I have received Permanent Cosmetics to seek help with my primary physician or an emergency room, immediately.

Initial*I am aware that touch-ups are NOT included in the cost of any initial service.
Are you pregnant or nursing? *

Yes No
Have you had COVID-19 vaccine? *

Yes No
ACCEPTANCE AND ACKNOWLEGEMENT

I have read and understand these risks listed above and they have been explained to me. I certify that the information in the above questionnaire is accurate and my questions have been answered.

**Please read all questions thoroughly before signing**
CLIENT SIGNATURE (YOU MUST SIGN THIS!) *

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PHOTOGRAPHY RELEASE CONSENT
We would like your permission to use these photos for advertising. For example, in portfolios, online and in print ads, etc. Please be advised that no artist will be authorized to share your pictures on their personal social media accounts. Photos will only be publicized on the company's social media accounts. Your consent is necessary regarding this.
Please check the box and indicate if you would like your photos used or not regarding any and all advertising/marketing under Arch Angels NYC / NJ ONLY. *

YES, USE THEM! NO, PLEASE DON'T USE THEM YES, BUT BROWS OR PMU AREA ONLY!
Specia requests, concerns or remarks for artist:
CLIENT SIGNATURE (YOU MUST SIGN THIS!) *

Clear
Date *

Month Day Year
Should be Empty:

CLIENT CONSENT/MEDICAL FORM

Brow Lamination History

GENERAL MEDICAL QUESTIONS

INFORMED CONSENT TO PROCEDURE

PHOTOGRAPHY RELEASE CONSENT