Microblading Consent Form Template

Microblading Consent Form

City Brows
Date

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
How were you referred?
Microblading

Microblading is a tattooing technique in which a small hand held tool is used to add pigment into the skin. A touchup session is recomended 4 to 6 weeks after application in order to maintain the effect. Signs of symptoms of allergic reaction: Swelling that extends into the eyelids or other places on the face, Redness that extends beyond the eyebrow and up into the scalp or cheek area, Warmth when touching the red areas, Tenderness and/or pain to your face/eyebrows, Fever or chills or increase in sweating (signs that suggest you have a systemic infection), Drainage or foul discharge from the procedure site. Sign below that you understand the procedure to be performed:
Signature*

Clear
Have you previously had eyebrow permanent makeup? If so, upload image below.

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Permanent Makeup Consent

I acknowledge by signing this release form that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from City Brows owner Chantay Richards. I acknowledge that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and I agree as follows:
Signature*

Clear
I acknowledge that the following information Is true.

I am not under the influence of alcohol or drugs. I do not have acne, freckles, moles, or sunburn in the area to be tattooed that might be agitated by the tattoo process (healing excluded). I acknowledge that I am not pregnant. I acknowledge that I am free of communicable disease. I acknowledge that I have truthfully represented to the associates, agents and representatives of City Brows that I am over eighteen (18) years of age. I acknowledge it is not reasonably possible for representatives, artist of City Brows to determine whether I might have an allergic reaction to the dyes, pigments, or processes used in my tattoo and I agree to accept that such risks are possible. I acknowledge that infection is always possible as a result of obtaining a tattoo particularly in that event that I do not take proper care of my tattoo, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical care. I acknowledge receipt of written instructions advising me of proper care of my tattoo and recognize the absolute necessity of following those written instructions. All questions about the body art procedure have been answered to my satisfaction. I acknowledge that variations in color and design may exist between any tattoos as selected by me and as ultimately applied to my body. I acknowledge that tattooing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove my tattoo. I acknowledge that the obtaining of my tattoo is my choice alone and I consent to the application of the tattoo and to any actions or conduct of the associates, agents or representatives of City Brows that are reasonable necessary to perform the tattoo procedure. I agree to release and forever discharge and forever hold harmless City Brows and its associates, agents officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo and any and all tattoos applied by Chantay Richards and its associates, agents and representatives in the future. I acknowledge that tattoo inks, dyes and pigments have not been approved by the federal Food and Drug Administration and the health consequences of using these products are unknown. I acknowledge that there is a chance I might feel lightheaded, dizzy during or after being tattooed. I agree to immediately notify the practitioner in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. I agree to follow all instructions concerning the care of my tattoo, and that any touch-ups needed because of my own negligence will be done at my own expense. I authorize my technician to take photographs of the work performed both before and after the treatment and I authorize the use of the photographs to be used for advertising.
Signature*

Clear
I have been fully informed of the risks of tattooing including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, and latex gloves. Having been informed of the potential risks associated with getting a tattoo, I still wish to proceed with tattoo application and I assume any and all risks that may arise from tattooing.
Signature*

Clear

Contact in case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number

	Yes	No
Currently Pregnant
Currently Breastfeeding
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)
Had undergone Botox treatment
Has or any family history of Diabetes
Has Hepatitis A B C D
Had Forehead/Brow Lift
Had Facelift Surgery
History of Alcoholism
Has a Heart Condition
Had a Brow Lash Tinting
Has Autoimmune disorder
Has Oily Skin
Has, had, or any family history of having Cancer
Had undergone Chemotherapy/ Radiation
Taking or have taken acne treatments in the past 3 months
Had a Tan treatment
Difficulty numbing with dental work
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc
Allergic reaction to any medications
Allergies to metals, food, etc,
Any diseases other than listed here
Do you use facial care treatments?