MICROBLADING CONSENT FORM

MICROBLADING CONSENT FORM
NAME

First Name Last Name
DATE OF BIRTH

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER
Please enter a valid phone number.
BEFORE MICROBLADING:

4 WEEKS BEFORE:
- NO filler treatments, retinol, chemical, peels, microdermabrasion, exfoliation treatments, or AHA's
2 WEEKS BEFORE:
- NO botox
48 HOURS BEFORE:
- DO NOT consume alcohol, caffeine, blood thinners, or pain killers, and avoid working out
PLEASE READ AND CHECK ALL THAT APPLY

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 it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of 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 said procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each indivudal’s reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent. I understand that there may be certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Secondary infection in the area of the procedure may occur, however if properly cared for, is rare. 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. I authorize my technician to obtain pre-procedural and post-procedural photos and give my technician permission to use such photos for publication and/or for teaching purposes, as they choose. I have informed my technician of any existing health problems. Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have any questions, I will call/email my technician. I understand that sun, tanning beds, pools, some skin care products, and medications, can affect my permanent makeup. I understand that because pigments used in permanent cosmetic procedures contain iron oxide, there may be a warming/tingling sensation in the area of my procedure during an MRI, therefore I must advise my physician that I do have a cosmetic tattoo, in the event an MRI is prescribed. I accept the responsibility to explain fully to you my desire for specific colors, shapes, and positions for any procedure done today and that there is no refund policy. I have received pre- and post-procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. I accept full responsibility for the decision to have this cosmetic tattoo work done. I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure and I have had the opportunity to ask questions and all of my questions have been answered.
POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS:
- PAIN: There can be pain even after topical anesthetic has been used.
- INFECTION: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See the "After Care" sheet for instructions on care.
- UNEVEN PIGMENTATION: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance.
- 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 correct unevenness.
- EXCESSIVE SWELLING OR BRUISING: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears within 1-5 days. Some people don't bruise or swell at all.
- ANESTHESIA: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these, please inform me now.
- ALLERGIC REACTION: There is a possibility of an allergic reaction to the pigments or other materials used. You may 5-7 day patch test to determine this.
Do you presently have or previously had any of the following? CHECK ALL THAT APPLY.

History of MRSA Forehead/Brow lift Diabetes Face lift Abnormal Heart Conditon Chemical peel Brow tinting Oily skin Accutane or acne treatment tan by booth or sun taking blood thinners botox Hepatitis (A,B,C,D) Easy bleeding Alcoholism Currently pregnant/breastfeeding Autoimmune disorder Cancer Chemotherapy/Radiation Tumors/growths/cysts Allergic reaction to any medications Allergies Retin-A, glycolic acid, or alpha hydroxyl
BROW AFTERCARE
- Wash brows morning and night for 10 days with Lash and Blade Brow Cleanser.
- After following your cleansing aftercare process, apply healing balm, morning, afternoon and night for 10 days to ensure optimal retention.
- Rice grain size amount will cover both brows.
- NO makeup on them for 10 days
- NO direct sunlight for 10 days
- NO picking or rubbing scabs
- NO sweating
- NO submerging in water, pools, etc.
- Use sunscreen on them once they're healed
SIGNATURE

Clear
DATE

Month Day Year
Should be Empty: