DAY OF APPT Microblading | Powder Brows | Lips

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ONLY complete this form on the day you are receiving Powder Brows, Combo Powder Brows, Microblading, Permanent Eyeliner or Lip Blushing.* This field is required.Do not complete this form unless you are receiving any of the above services the same day.
I am getting one of the above services TODAY.I am not getting one of these services on this calendar day. (Please, Do NOT continue, simply exit and come back later.)
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Today's Date* This field is required.
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Name
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Date of Birth* This field is required.You must be 18 years or older.
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Phone Number* This field is required.
Please enter a valid phone number.
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I have completed an in-person consultation and my candidacy for treatment has been determined.* This field is required.
I agree
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Are you currently or have you ever used medications that contain a controlled substance?* This field is required.
Yes
No
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Have you ever been diagnosed by a medical doctor as to having contracted communicable disease such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and/or other blood borne pathogens. If so, when?* This field is required.
Yes
No
Other
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Have you ever been diagnosed by a medical doctor as having allergies?* This field is required.
Yes
No
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Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?* This field is required.
Yes
No
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By typing my full name below, I certify that I am over the age of 18 and can legally receive tattooing in the state of Missouri.* This field is required.
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Have you taken Accutane or generic Isotretinoin within the last 12 months?* This field is required.
Yes- Unfortunately, you are not a candidate.
No
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Are you currently under the influence of any illegal substance?* This field is required.
Yes
No
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Are you currently under the influence of an alcoholic beverage?* This field is required.
Yes
No
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7. If yes to cancer, please list treatments received and the date ended.
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Have you been diagnosed with jaundice within the past 12 months?* This field is required.
Yes
No
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Are you currently using any medications that contain blood thinners?* This field is required.
Yes
No
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Are you currently using any medications that weaken the immune system that fights infections?* This field is required.
Yes
No
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8. History of keloid scarring?* This field is required.
Yes- Unfortunately, you are not a candidate.
No
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9. History of tattoos or permanent or semipermanent cosmetics?* This field is required.
Yes
No
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10. History of MRSA?* This field is required.
Yes
No
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Please explain.
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12. Allergic reaction to any medications?* This field is required.
Yes
No
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13. If yes to medication allergies, please list below.
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14. Are you taking any blood thinners, medications that may thin the blood, pain medication or medication that weakens the immune system?* This field is required.
Yes
No
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15. If yes to above, please list below. Note that you must not be taking any blood thinning medications while receiving permanent makeup.
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16. If you've had Botox (or similar) injections in your face, input the date of your last treatment and state the area treated below the date. If no history of injections, type NO in the box below the date box.
Month
Day
Year
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17. Are you prone to cold sores or fever blisters? If Yes, and you plan to receive Lip Blushing, it is recommend to take Valtrex or similar for 2 weeks prior to lip procedures to prevent an outbreak. *Even with proper precautions taken and no history of cold sores, an outbreak is still possible.* This field is required.
Yes, I understand and accept the risk of an outbreak.
No history of outbreaks, but I understand an outbreak could still be possible and I accept the risk.
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20. Do you have any abnormal heart conditions?* This field is required.
Yes
No
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22. Do you have difficulty numbing during dental procedures?* This field is required.
Yes- I understand that my permanent cosmetics procedure may be more uncomfortable.
No
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23. Have you had any laser treatments or chemical peels in the last 30 days?* This field is required.
Yes, and I understand I cannot receive laser or chemical treatments within 4 weeks of my permanent cosmetics procedure.
No
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24. Do you have an autoimmune disorder?* This field is required.
Yes
No
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25. If yes to autoimmune disorder, please list type and medication- note that if you have trouble healing wounds, you are not a candidate for permanent cosmetics.
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26. Do you have oily skin?* This field is required.
Yes- I understand I cannot receive Microblading but I may be a candidate for Powder Brows and this will be determined at my consultation.
No
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27. Do you use any products containing retinol?* This field is required.
Yes- you must discontinue use for 4 weeks prior to appointment.
No
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28. Are you allergic to metals?* This field is required.
Yes
No
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27. Do you use any retinol products?* This field is required.
Yes- You must discontinue use for 4 weeks prior to appointment
No
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28. Are you allergic to metals?* This field is required.
Yes
No
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Aftercare instructions will be explained to me and I will follow the instructions to the best of my ability.* This field is required.
I understand
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I understand that a certain amount of discomfort can be associated with this procedure and that swelling, redness, and bruising can occur.* This field is required.
I understand
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I understand that Retinols, Alpha Hydroxy and Glycolic Acids must never be used on the treated areas as they will alter the color and cause premature fading.* This field is required.
I agree
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I understand that sun, tanning beds, pools, some skin care products, nicotine use, medications and not following after care instructions can affect my permanent cosmetics.* This field is required.
I understand
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I accept responsibility for explaining my desire for specific colors, shape, and position prior to the procedure.* This field is required.
I accept
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I understand that the implanted pigment color will change and fade over time due to circumstances beyond our control and I will need to maintain the color with future applications, however this procedure is still considered permanent.* This field is required.
I accept
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I understand that under NO circumstances can my skin be reopened in an attempt to make changes big or small before the required healing time of 6 weeks.* This field is required.
I accept
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I understand that my genetics and aftercare affect 80% of the outcome of my healing. If my skin requires additional applications, it will be at an additional cost to me.* This field is required.
I accept
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I understand that absolute perfection is not a reasonable nor realistic expectation and I am open to vastly improving my features as best as they can be improved.* This field is required.
I accept
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I understand that the colors and saturation will change during the healing process and 2 or more sessions may be necessary.* This field is required.
I accept
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34. I understand that the implanted pigment color will change and fade over time due to circumstances beyond our control and I will need to maintain the color with future applications, however this procedure is considered permanent.
I agree
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35. I understand that under NO circumstances can my skin be reopened in an attempt to make changes big or small before the required healing time of 6 weeks.
I agree
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36. I understand that my genetics and aftercare affect 80% of the outcome of my healing. If my skin requires additional applications, it will be at an additional cost to me.
I agree
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37. I understand that absolute perfection is not a reasonable nor realistic expectation and I am open to vastly improving my features as best as they can be improved.
I agree
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Please read the following aftercare instructions.

Day 1: Absorb

Gently blot treated area with a clean tissue to absorb excess lymph fluid. Do this every hour until oozing has stopped~3/4 hours. Removing this fluid prevents hardening of the lymph (a scab).

Days 1-7: Wash

Wash treated area daily to remove bacteria and dead skin. (Don't worry...THIS DOES NOT REMOVE THE PIGMENT!)

Gently wash your brows, eyes, and/or lips each morning and night with cool water and the cleanser provided to you. With a very light touch, use your fingertips to gently rub the area in a smooth motion for 10 seconds and rinse with water ensuring that all soap is rinsed away. Let air dry. DO NOT use any cleansing products containing acids (glycolic, lactic, or AHA), any exfoliants, wash cloths or brushes on your fresh permanent cosmetics. Make sure to keep your aftercare kit after your first 7 days. You will use it again after your touch up appointment. Additional kits are available for purchase in studio.

Days 1-7: Moisturize

Very gently, apply a rice grain amount of ointment provided to you with your clean fingertip. Be sure not to over-apply as this will suffocate your skin and delay healing. The ointment should be barely noticeable on the skin. Never put the ointment on wet or damp skin and do not rub vigorously. Apply the ointment 2 times per day or more, but only if the treated area feels overly tight or dry. Make sure to keep your aftercare kit after your first 7 days. You will use it again after your touch up appointment. Additional kits are available for purchase in studio.

Important Reminders

Your permanent brows, eyes or lips will get darker in color before they get lighter, expect them to feel "too dark" in the first week.

Your overall pigmented area will shrink and change shape within the first week due to swelling.

Use a fresh pillowcase.

Let any scabbing or dry skin naturally exfoliate away; picking can cause scarring or loss of color.

No facials, botox, chemical treatments or microdermabrasion for 4 weeks.

Avoid all exercise for 3 days, avoid strenuous sweaty exercise for 10 days. When working out, do not wipe your treated area- this could remove any flakes or scabs prematurely and result in uneven pigment retention.

Avoid direct sun exposure or tanning for 4 weeks after the procedure, wear a hat and sunglasses when outdoors.

Avoid heavy sweating and long hot showers for the first 10 days, keep showers cool and limit to 5 minutes*.

Avoid sleeping on your face for the first 10 days.

Avoid swimming, lakes, hot tubs for the first 10 days.

Avoid topical makeup including sunscreen on the area for 10 days.

DO NOT rub, pick or scratch the treated area.

*Limit your showers to 5 minutes so you do not create too much steam. Keep your brows, eyes or lips out of the water while you wash your body, then, at the end of your shower, wash your hair. Avoid excessive rinsing, direct pressure from shower head and hot water on the treated area.

Typically, your brows will require maintenance sessions every 18 months with microblading and every 2-4 years with powder brows, depending on your skin type.

Permanent Eyeliner will require

maintenance sessions every 2-5 years.

Lip Blushing will require maintenance sessions every 1-2 years.
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39. I have read the above information and understand how to prepare for my appointment. Any questions I have I will address during my pre-appointment consultation.* This field is required.
I agree
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38. I understand that microblading is a 2 step appointment and I will be healing and my brows will change during that time.
I agree
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I agree to use electronic records and signatures.* This field is required.
Yes, I agree
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Signature* This field is required.
Clear
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I acknowledge that the proposed procedure involves risks inherent to the procedure and has possibilities of complications, although rare, during and/or following the procedure such as: infection, poor color retention based on skin type and genetics or hyper-pigmentation. I certify that I have read the contents of this form. I understand the risks and alternatives involved in the procedure and will or have had the opportunity to ask questions and all of my questions have or will be answered. I acknowledge that I have reviewed and approved the material given to me and I authorize Jamee Mittell Esthetics Studio to perform this procedure.
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I acknowledge that the proposed procedure involves risks inherent to the procedure and has possibilities of complications, although rare, during and/or following the procedure such as: infection, poor color retention based on skin type and genetics or hyper-pigmentation. I certify that I have read the contents of this form. I understand the risks and alternatives involved in the procedure and will or have had the opportunity to ask questions and all of my questions have or will be answered. I acknowledge that I have reviewed and approved the material given to me and I authorize Jamee Mittell Esthetics Studio to perform this procedure.* This field is required.
Clear
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* This field is required.
I agree
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Photo Release: I grant Jamee Mittell Esthetics Studio and it's employees permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph, likeness and statements, including, but not limited to, before and after pictures of my eyes/eyebrows/face in connection with the promotion of the service or the products used in the services (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my Signature is not present at the end of this paragraph, then the above-described permission has not been granted.* This field is required.
I agree to use electronic records and signatures.
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I attest that I will not be under the influence of drugs or alcohol before or during my procedure. And I will not consume alcohol nor caffeine for at least 24 hours before my appointment.
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Signature* This field is required.
Clear
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I, the undersigned, acknowledge that I am aware certain medical conditions and treatments and/or medications used to treat those medical conditions may be adversely impacted by the procedure(s) of tattooing and/or body piercing and/or branding. Such medical conditions include but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medications that weaken the immune system. I further acknowledge that the tattoo and/or brand should be considered permanent; that said tattoo and/or brand can only be removed with a surgical procedure; and that any effective removal may leave permanent scarring and disfigurement. I have read this form and confirm that all the information I have given is correct. I understand that this is a consent form and I agree to be legally bound by it.* This field is required.
Clear
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I release Jamee Mittell Esthetics Studio from any and all liability or claims. I agree that all of the above information is true and accurate to the best of my knowledge.* This field is required.
Clear
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Photo Release: I grant Jamee Mittell Esthetics Studio and it's employees permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph, likeness and statements, including, but not limited to, before and after pictures of my eyes/eyebrows/face in connection with the promotion of the service or the products used in the services (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my Signature is not present at the end of this paragraph, then the above-described permission has not been granted.
Clear
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Jamee Mittell Esthetics Studio does not guarantee the outcome of your permanent makeup.* This field is required.
I understand
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Are you pregnant or breastfeeding?* This field is required.
Yes- Unfortunately, you are not a candidate.
No
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