Microblading Consent Form

DISCLOSURE & RELEASE AGREEMENT FOR COSMETIC TATTOOING/ MICROPIGMENTATION

Please read and fill out this “Disclosure & Release Agreement” completely, making certain that you understand all information provided, and that your information is correct. You have the right to be informed so that you may make the decision whether or not to undergo the procedure, after knowing the risks and hazards involved. This disclosure is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure. Please read and INITIAL the statements below to indicate: I understand the following completely.

eKtra Beauty is obligated to perform procedures in strict compliance with all hygiene and health protection measures. This information is confidential and it shall be handled with care for the protection of all clients and any shared information.

Name*

PrefixFirst NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email *

Health Questionnaire

In order to perform the eyebrow Microblading procedure in a safe manner, please answer the following questions truthfully.

Do you suffer from the following diseases or are you taking any of these medications?*

	Yes	No
Hemophilia
Diabetes mellitus
Hepatitis A B C D E F
HIV
Skin Diseases
Eczema
Allergies
Autoimmune disease
Are you prone to Herpes
Infectious Disease
Epilepsy
Cardiovascular problems
Do you have a pacemaker?
Are you taking medication for blood thinning?
Are you pregnant or nursing?
Do you have problems with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?
Did you undergo any surgery in the last 14 days?
Were you exposed to radiation or had any other medical interventions?

PROCEDURE EXPLAINED

During the procedure, despite the staff expertise and all the precautionary measures, injury is possible. Despite the application of the most advanced and top quality pigments, allergic reaction is possible, but rare. The client is informed about this and he/she assumes liability. During and after the procedure temporary swelling, redness and or itching may occur. Depending on the skin structure after the first treatment, small scabs with a loss of drawn hairs may occur and colour intensity may change.

BROW COLOR AND HEALING PROCESS

In the first seven days, eyebrows are up to 40% darker and 10-15% thicker. Colour reflection depends on the natural skin pigment. The Pigment is absorbed differently due to differences in the skin quality, thus there is no warranty for the treatment success. The shape is determined according to the face proportions. Depending on the skin structure, it should be noted that change in the colour intensity is possible and that one or more additional treatments will be required. The minimum or maximum duration of microblading or permanent makeup procedures cannot be determined with certainty nor can the warranty be given on performed treatment.

TOUCH UPS

Any touch up fees may apply for future appointments if touch ups are desired. If most of the colour has faded, then this will not be considered a touch up and all fees for a new service may apply.Touch ups are currently $50, and is usually performed after 6-8 weeks. For oily skin it may be necessary to perform more corrections. Permanent makeup always leads to skin injury. Therefore, it is important to carefully and gently nurture your skin after the treatment to allow healing without complications. Inadequate care in the healing phase of the skin can lead to poor results for which Rakisha (eKtra Beauty) cannot be held liable. Permanent makeup is an art and not science. Clients result will vary and using make up pencil or brow powder may still be needed.

AFTER CARE IN THE NEXT TEN DAYS YOU ARE REQUIRED TO PAY ATTENTION TO THE FOLLOWING:

Keep your eyebrows dry and clean for the next 10 days. Do not contact with water. A thick crust will appear and all the pigment will fade. Do not touch the scab in any other case except while cleaning. For post treatment care, only use recommended liquids to clean the brows (sterile water for the first day only). Please do not use any other creams except the ones provided or recommended to you in order to prevent possible infections or allergic reactions. In the first two weeks after the treatment avoid swimming pools, sunbathing, tanning beds (no sun or tanning for 30 days), sauna, beauty treatments, and intense training accompanied by sweating (sport activities), and avoid contact with dirt/dust. Rakisha (eKtra Beauty) and their technicians are not liable in case of improper post treatment care.

PHOTO CONSENT FORMS*

YES, I would like to give my consent for my before/after photos to be shown on social media (Instagram/Facebook/ Twitter/etc and in printed materials. (Your face will not be shown and you will not be tagged in the photo. Just a photo of the work that was done.)NO, I would NOT like to give my consent for my before/ after photos to be shown on social media.

Date

TOUCH UP APPOINTMENTS

Touch up appointments typically occur 4-6 weeks after the first appointment. Please choose the soonest available date you could be available for your touch up. Appointment is not confirmed and can be changed based on the availability of your technician.

**Touch up appointments are $50.**

Date Reservation

Location

No food, drinks, or making/receiving phone calls are allowed in the procedure area. Minimal texting or email is totally fine, as long as it does not interfere with the procedure. (This applies to any guests of the client as well No warranty has been made to me as a result of this semi permanent makeup, micro-pigmentation or correction procedure, and that the final result cannot be guaranteed.

Microblading/Permanent Cosmetics Consent Release Form