Beauty Marks Consent Form & Deposit

MICROBLADING PRE-TREATMENT ADVICE AND PROCEDURES

Delicate or sensitive skin areas may swell or redden, it is advised not to make social plans on the day of the procedure.
Do not resume any method of hair removal for two weeks following the procedure. Electrolysis should be avoided at least five days prior to the procedure.
Must refrain from dying/ tinting eyebrows at least 48 hours before the procedure. Wait one week after the eyebrow procedure before dying brows.
Do not use aspirin or ibuprofen for 7 days prior to your procedure.
There must be a month between Dysport, Botox, or filler injections and permanent cosmetic services.

I, {name}, as a client have requested that you describe the procedure so that I may make an informed decision whether or not to undergo the procedure.

You have described the recommended procedure to be used as Micro Pigmentation, the process of implanting micro-insertions of pigment into the epidermal layer of skin. Micro Pigmentation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.

I voluntarily request Megan Marks as my permanent cosmetic technician to perform microblading on my eyebrows.

I understand that this description of the procedure is not meant to scare or alarm simply an effort to make me better informed. I acknowledge that I may give or my consent for this procedure.*

I have informed my technician that I am in good health and I am not under the care physician.*

Only fill out this bottom portion if you are under the care of a physician for a serious medical reason.

Physician's Name

Phone Number

Address

City

State

Zip

I understand that allergic reactions to pigment are very rare, however, are possible.*

I understand that this procedure will involve pain and discomfort.*

I understand the markings are permanent and that there is a possibility of hyperpigmentation resulting from a procedure, especially in individuals prone to hyperpigmentation from a scar or other injury.*

I understand that a follow up procedure may be required.*

Other risks involved with the procedure may include, but not limited to: infections, and other reaction (s) to applied pigments, allergic and other reaction (s) to products during and after the procedure, fanning or spreading of pigment (pigment migration), of color and other unknown risks.*

I accept full responsibility for any and all, present and future, medical treatment (s) expenses I may incur in the event I need to seek treatment (s) for any known or reason associated with the procedure planned for me.*

I have been given an opportunity to ask questions about the procedures and the to be used and the risks and hazards involved and I believe that I have sufficient to give this informed consent.*

I certify this form has been fully explained to me and I have read it or it has been me. I understand its contents.*

I have read the Post Procedure Instructions and understand that I will a physical copy along with verbal instructions immediately following the procedure.*

I understand that there may be some pain involved during the procedure. Each has a different tolerance level and pain felt will be according to each individual's pain*

I understand that other adverse side effects, although rare, can include swelling, minor bleeding, redness and pinkness, and soreness.*

I understand that there will be some fading of color. (Fading occurs more frequently with oily skin.) The technician has not guaranteed me as to how much color will stay. *

| understand that Permanent Makeup is a process and often requires several touch-up applications. I also understand that two or more applications of color (touch-ups) may be necessary to receive the desired outcome. Each touch-up appointment is an additional cost. We do not provide free services, under no circumstances. *

I accept full responsibility for the color and shape of each and every procedure I receive. I take full responsibility for my eyebrows in regards to shape, color, and placement.*

**CAUTION THERE MAY BE RISKS ASSOCIATED WITH THE PROCEDURE OF COMMERCIAL BODY ART, WHICH INCLUDES PERMANENT TATTOOS, BODY PIERCING, AND PERMANENT COSMETIC APPLICATION, THAT MAY ADVERSELY AFFECT THE HEALING PROCESS IF YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING

DIABETES, HISTORY OF HEMOPHILIA (BLEEDING), HISTORY OF SKIN DISEASES, SKIN LESIONS OR SKIN SENSITIVITIES TO SOAP, DISINFECTANTS, ETC., HISTORY OF ALLERGIES OR ADVERSE REACTIONS TO PIGMENTS, DYES, OR OTHER SKIN SENSITIVITIES, HISTORY OF EPILEPSY, SEIZURES, FAINTING, OR NARCOLEPSY, PREGNANCY OR BREAST-FEEDING/NURSING, IMMUNE DISORDERS, OR SCARRING (KELOID)

Signature*

Clear

Date*

Date

Today's Date*

Date

Name*

City*

Home Phone*

Employer *

Occupation*

Emergency Contact*

Are you currently taking any medication? If yes, is it considered a blood thinner? Please explain*

Do any facial products you use contain RetinA and/or Glycolic Acid? If YES, please refrain from using these products for at least a month after the procedure.*

List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams, pigments or dyes) : *

Have you recently undergone a skin peel?*

Do you have or have you ever had any of the following conditions? (MUST ANSWER YES OR NO)

Abnormal Heart Condition*

Cold Sores*

Hemophilia (bleeding)*

Visual Disturbances*

High or Low Blood Pressure*

Scarring (Keloid)*

Tumors/Growths/Cysts*

Circulatory Problems*

Chemotherapy/Radiation*

Epilepsy*

Are you pregnant?*

Narcolepsy*

Breast feeding/nursing*

Diabetes*

Hepatitis*

Fainting Spells/dizziness*

Do you use tobacco products?*

History of skin lesions*

Seizures*

History of skin diseases*

Glaucoma*

Immune Disorders*

Have you ever experienced hyperpigmentation from an injury?*

Are you currently taking aspirin or ibuprofen?*

Do you have a history of cancer? If Yes, When?*

Are you currently receiving chemotherapy or radiation treatments? Examining Physician:*

*Beauty Marks shall not perform services on a person who is inebriated or incapacitated by the use of alcohol or drugs. Services will not be performed on persons with sunburn or other skin diseases or disorders (i.e., open lesions, rashes, wounds, punctured skin), psoriasis, or eczema present in the treatment area.

Signature*

Clear

I hereby authorize Megan Marks to take photographs of the work performed both and after treatment, and I further authorize the use of said photographs to be used for of advertising.

I hereby authorize Megan Marks to take photographs of the work performed both and after treatment to be maintained only on file.

CLIENT SIGNATURE*

Clear

DATE*

Date

Please keep in mind that the following listed will play a huge part in the way your results appear after you’re finished healing.

Heart Conditions/Pace Maker/Defibrillator (No exceptions)
If you are any of these medications, you will bleed and the pigment may not retain: Triflusal (Disgren), Clopidogrel (Plavix), Prasugrel (Effient), Ticagrelor (Brilinta), Ticlopidine (Ticlid), Cilostazol (Pletal), Vorapaxar (Zontivity), Dipyridamole(Persantine
Coumadin), Pradaxia (dibigatran), Xarelto (rivaraxaban), Eliquis (apixaban), Savaysa (edoxaban)
Shingles (No exceptions)
If you’ve ever had Shingles on your face, Microblading will not be performed, as the procedure could cause a flare up
Eczema, Psoriasis or Dermatitis in or around the brow area
Constant flaking/itching/irritation/shedding of skin
Oily or severely oily skin- The hair strokes will appear more blended, solid or not retain as much (Microblading only)
Large pores on your forehead & in the brow area- Pigment will blur/blend in large pores looking powdered. (MIcroblading Only)
Hemophilia-Bleeding Disorder- Pigment may not retain

Platelet Disorders - Aggregation Disorders An aggregation disorder is when platelets do not bind with fibrinogen and other proteins in order to stick to other platelets. As a result the platelets cannot form a plug to stop the bleeding from a damaged blood vessel. Moles/Skin Tags in or around the brow area Pigment will not be put into anything raised.
Piercing in the brow area. Scars can cause the pigment to migrate
Deep wrinkles in the brow area The hair strokes will not lay properly in the creases, giving the brow an uneven look
Thyroid condition and taking medication for this condition Hypo, Hyper Thyroidism, Graves Disease, Hashimotos
Fitzpatrick Skin types 1 (red heads/white skin/light eyes) Due to hypersensitivity the skin may not take the pigment well.
On Accutane (acne medicine) within the last 6 months
Auto Immune Disorder of any kind (MSRA, Lupus, HIV/AIDS or the like) Due to the medicines to treat these diseases, pigment will not retain (No exceptions for MRSA, can be highly contagious)
Extremely Thin skin Transparent or Translucent or very vascular
Frequent Exercise Due to the frequent production of sweat (salt), the pigment WILL NOT retain, fade very quickly, appear blurred or change in color
If you work out regularly (5-7 days a week), your eyebrows WILL fade very fast due to the production of salt/sweat. Salt is used to remove permanent makeup. They WILL appear more powdered or blurred under the skin as well. Microblading Techs reserves the right to refuse future services if she feels the results won't be to
ABSOLUTELY NO SUN 30 DAYS AFTER (This means you cannot go out in sun with a hat and glasses on, this means no SUN or HEAT FOR 30 days at all) If you resume tanning, the results will fade quickly, heal darker, or not retain at all

CLIENT SIGNATURE*

Clear

DATE*

Date

Please Upload a Photo of your Drivers License*

My Products

Microblading DepositA nonrefundable $100 deposit is required to hold your appointment. The $100 will go towards the service total which is due on the day of the appointment. If appointment is rescheduled within 24 hours of their appointment, the $100 will be transfer to the rescheduled date. If appointment is canceled or rescheduled with less than 24 hours notice the deposit will be forfeited and a new deposit will be required to rebook. If client does not show to their appointment the $100 will be forfeited and client will not be able to book future appointments.

$100.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

Medical History

CLIENT PHOTO RELEASE FORM

Credit Card