MICRO-BLADING & PERMANENT EYEBROWS CONSENT FORM

Name

First NameLast Name

Occupation

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referred by:

To avoid unforeseen complications, please CHECK ALL that apply to the following questions:

Do you have previous Permanent Make-Up? If yes when?

I am over the age of 18. If I am not I have a parents consent and understands the risk of the procedure.

This is my parental and/or guardian signature. My parent and/or Guardian understands the risk that may be involved with procedure and consents.

Print Parental/Guardians name:

first and last name

Have you had Botox or injectables? If yes when?

Have you had Aspirin or any blood thinning medications/supplements with in the last 7 days?

Do you take Antidepressants or mood altering medication?

Have you had chemical or laser peel? If so when?

Do you have any problems with healing?

Do you get fever blisters or cold sores?

Do you currently or have you had Cancer? If yes please explain

Are you currently under going radiation or chemotherapy?

Are you currently using Retin-A or Alpha Hydroxyl skin care products?

Do you wear contact lenses?

Have you had caffeine products in the last 24 hours?

Are you taking any medication, including immunosuppressive, such asanti-inflammatory or steroids?

Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or ___Caine family of drugs or Petroleum based products (Vaseline)?

Is there any history of skin diseases or remarkable skin sensitivities?

Are you pregnant or nursing?

Are you presently taking Vitamins A, E or fish oil in any form?

Are you required to take antibiotics during dental or invasive medical procedures?

Do you have any heart conditions?

Do you have Alopecia?

Are you currently on Accutane Treatment?

Do you have Keloid or Hypertrophy Scars?

Do you have Hepatitis?

Do you have Diabetes?

Any tendency to bleed excessively from minor cuts?

Do you have Epilepsy / Seizures of any kind?

Do you have any Autoimmune Disorders?

Do you have HIV?

Please list any other medical conditions, and list all:

Doctor’s Name and Number.

I am over the age of 18, I am not under the influence of drugs or alcohol. I am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.

Procedure:

Cost of Procedure:

With any Micro-blading and Permanent Make-Up (2) follow up visits are required.

The cost of the follow up visits are not inculed in the price of the first service.

(Follow up cost are $175, but may vary.)

I have been informed of the nature, risks, and possible complications or consequences of semi-permanent pigmentation. I understand the semi-permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of procedure, including but not limited to the following: infections, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment maybe modified slightly, due to the tone and color of my skin. I fully understand this is a form of tattooing and there fore not an exact science, but an art. I request the semi- permanent skin pigmentation procedure(s),and accept the permanence of the procedure as well as the possible complications and consequences of Mirco-blading.

Initial

II understand that topical anesthetics, pigments, cleansers, and procedure-related products may cause temporary irritation , burning, sensitivity, allergic response, blurred vision, tearing, swelling, or discomfort. I acknowledge that these reactions may occur even if no prior sensitivities are known and are not indicative of negligence.

Initial

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. I consent (initial) or waive (initial) the patch test. If waived, I release the technician from all liabilities if I develop an allergic reaction to the pigment. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, It may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.

Initial

I release Liza Neginsky (Elizaveta Neginskaya and EN Signature Brows & Beauty Studio), Kanjana Sutton, and Krissy Saito, from any and all liability related to temporary reactions, medical visits, discomfort, or personal sensitivities arising from the procedure or products used.

Initial

I understand that the provider is not responsible for lost wages, incidental expenses, transportation issues, personal accidents, or secondary costs related to recovery.

Initial

I have received both pre and post care procedural instructions and I will strictly adhere to such instructions. I understand that my failure to do so many jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly adhere to my doctor’s instructions before contemplating any semi-permanent cosmetic procedure around the lips.

Initial

PLEASE LIST ANY ALLERGIES/SENSITIVITIES YOU MAY HAVE. IF APPLICABLE PLEASE NOTIFY YOUR AESTHETICIAN AND CONSENT TO THE QUESTION BELOW!

If applicable, please read the bottom question carefully!

I understand that taking before and after photographs of the said procedure are a condition of the procedure. I give Elizaveta Neginskaya permission to take, publish and reproduce photographs of me, my face, and/or my eye area, both before and/or after the procedure for advertising and other purposes.

Initial

I certify that I have read and initialed the above paragraphs and that the consent and procedure permit have been fully explained to me. I accept full responsibility for my decision to undergo this cosmetic tattoo procedure. I understand that all treatments involve certain risks and that complications or side effects may occur from known or unknown causes. I voluntarily assume these risks and confirm that I have informed my aesthetician of any allergies, sensitivities, or reactions I may have.

Post Procedural Care for Eyebrows:

DAY 1: Do not wash the eyebrow areafor the first 24 hours. Keep area free of other ointments and make-up.

DAY 2-7: Keep eyebrows lightly glossed with the Ointment for three to four times a day for the next 7 days. Do not over use ointment. It should last you for 7 days, only apply very thin layer. Do not suffocate your eyebrows.

FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN LOSS OF PIGMENTS:

1. Do not use any Retin-A, Glycolic Acids, Peroxide, Neosporin while healing
2. Do not scrub or pick your eyebrows.
3. Do not expose area to sun or tanning beds! Must use hat if in the sun.
4. Avoid any facials, swimming, whirlpools or sanua for 7 days.
5. Do not exercise the first 3-5 days. No heavy sweating!
6. No make-up on the eyebrows!
7. Do not tint eyebrows for the next 10 days

WHAT TO EXPECT AFTER MICROBLADING OR EYEBROW SHADING PROCEDURES:

1.Slight swelling, thickness, and/or redness for one or two days following the procedure.

2. It is normal to lose approximately 50-60% of the color during the healing process.

3. After the initial procedure, the color may be a shade too dark; in six days it will appear to light after 10 days the color will show more.

4. It will appear softer when completely healed because the color will come from dermal layer of the skin to the epidermal layer of the skin.

5. Please be patient. Healing takes up to 30 days. In your next appointment more hairs can be added and make them perfect. The brows are approximately 20 to 25% darker and bolder in the width than they will be when healed. Your skin is red under the pigment which causes the color of the pigment to appear darker. There is some swelling, although difficult to actually see due to the thickness of the skin in the eyebrow area. This will subside. Exfoliation, which begins in afew days, will cause the excess pigment surrounding the eyebrow procedure to flake away and a narrower appearance of your eyebrows. Don’t be concerned that your eyebrows initially appear darker and heavier in size then you desire. This is all part of the process.

By signing this agreement, you comply with these terms. Please do not hesitate to contact us if you have any questions about the post procedural care.

REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for your self or for another individual are absolutely non-refundable. This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS.

Date

Please fill out email to receive after care instructions.

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