Lip Blush Medical and Consent Form

Name*

Date*

Date

Age*

Address*

Address

Street Address Line 2

CityState

Zip

Phone*

How did you select me for your procedure services?

Are you pregnant or nursing?

YesNo

Have you had any alcohol in the past 24 hours?

YesNo

Have you ever had cold sores or fever blisters? If yes, you must contact your health care provider for a prescription for Aciclovir for pre and post care.

YesNo

Do you have any allergies to latex?

YesNo

Have you had any laser or chemical peels in the area within the last 6 months?

YesNo

Do you bruise easily?

YesNo

Do you routinely use Retin-A, glycolic, or other exfoliating products?

YesNo

Are you allergic or sensitive to any metals, for example, metals used for jewelry?

YesNo

Do you have problems healing?

YesNo

Do you use tobacco?

YesNo

Do you have any heart conditions?

YesNo

Are you diabetic?

YesNo

Do you have any autoimmune disorders or thyroid disorders?

YesNo

Do you have Fillers in the area being treated?

YesNo

Do you have hyperpigmentation or hypopigmentation?

YesNo

Do you tend to keloid or form hypertrophic scarring?

YesNo

Do you tend to faint easily or get dizzy?

YesNo

Do you bleed excessively from minor cuts?

YesNo

Are you currently on any medications or treatments, if so, please list them.

Please initial each of the following sections.

Consent Release Agreement

This form is designed to give information needed to make an informed choice of wether or not to undergo lip blush semi-permanent makeup application. If you have questions please do not hesitate to ask. Although lip blush is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.

This is a process of inserting pigment into the dermal layer of the skin, a form of tattooing. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after each use. Cross contamination guidelines are strictly adhered to.

Generally the results are excellent. However, a perfect result is not a realistic expectation.It is common to expect touch-ups after healing is completed. Initially, the color will appear much more vibrant or darker compared to the end result. Usually within 7 days, the color will fade 50% (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.

Possible Risks/ Hazards/ Complications:

PAIN: There could be pain even after the topical anesthetic has been used. Aesthetics work better on some people than others.

INFECTIONS: Infection is very unusual. Less than 0.25% of the population has an allergic reaction. The area treated must be kept clean and only touched with freshly cleaned hands. You must follow the specific after care instructions provided to you.

UNEVEN PIGMENT: This can be a result of poor healing, infection, bleeding, or other causes. Your follow up appointment will likely correct any uneven appearances.

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 corrected and unevenness.

EXCESSIVE SWELLING/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. It typically disappears within 1-5 days. Some people do not bruise or swell at all.

ANESTHESIA: Typical aesthetics are used for numbing the area to be tattooed. Lidocaine in cream and gel form are used. If you are allergic to lidocaine please inform your technician immediately.

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 an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.

ALLERGIC REACTION: There is a small possibility of an allergic reaction, however this is not common.

SALON POLICIES

• A 50% NONREFUNDABLE deposit is required to book. Your deposit will go toward your appointment.

•There is a 48 hour reschedule policy, and a 15 minute late policy. If you reschedule prior to 48 hours, your deposit will transfer to your next appointment (1 time only). If you are 15 minutes late you run the risk of losing your appointment slot as well as your deposit. If you are late for a touch up appointment, you will have to place a new deposit for the rescheduled appointment.

• The studio accepts cash or major credit cards.

• Small children are not allowed in the room during the procedure. There is a waiting room, as well as one seat available in the work space for 1 guest. The appointment will typically take 2-3 hours, so please keep this in mind when inviting guests. Currently no guests are allowed during the Covid-19 Pandemic with extra safety precautions in place.

AFTERCARE INSTRUCTIONS

Day 1-2

Lips will be bright and a little plump. They will push out clear fluid called lymph. Keep this blotted off the lips for the first 24 hours. Keep clean and moisturized with the aftercare that is given to you at your appointment. Wash lips with warm soapy water, morning and night, and moisturize all day. Put it on and let it completely wear off before reapplying.

Day 3-4

Lips will becoming dry and peely. Do not pick or pull at them. It is very important that the skin naturally exfoliates and sloughs off. Picking can result in color loss and uneven healing.Keep lips moisturized and clean. Do not over apply! Let the lips breathe in between use of chapstick you are given.

Day 5-10

After peeling, lips may appear light in color and dry. Keep moisturized at all times and drink plenty of water. Make sure you stay out of the sun. Lips have new skin and will be very sensitive. No exfoliating yet.

During the next 2-6 weeks lips will change in color and soften to their desired shade. You may see lips fluctuate in color daily until you 6 week appointment. That is normal. Lip color takes time to balance out and heal entirely. You can now wear lip color if desired.

No sweating for 5 days

No exfoliating the lips for 2 weeks

No open bodies of water for 5 days

No laser on the lips, ever

No acids on the lips

No outside bodily fluid or bacteria for 5 days

Lip tattoos normally last 2-3 years depending on lifestyle, skin type, and aftercare.

Exposure to the sun and tanning beds can cause fading and discoloration of the pigment. Once completely healed, always apply sunscreen on the lip area.

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with its known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, the pigment may be modified slightly due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the microblading procedure and accept the permanence of the procedure as well as the possible complications and consequences of the procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each individual's reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases pigment is permanent*

I understand that several treatments may be needed in order to attempt to achieve my desired results. However, I have not received any guarantees to the quality of the outcome of the process*

I agree to submit to before and after photographs, and give my permission to use such photographs for publication and/or teaching purposes.*

I agree to follow all aftercare instructions provided by me by my technician.*

I have been duly informed of the natures, risks, possible complications and consequences as listed above. I further understand that my technician is not a medical doctor nor liable for any unforeseen outcomes.*

Client Signature*

Front of ID*

Back of ID *

Photo of lips, in natural lighting.*