Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl? Please list any medications you are taking

I agree that all the above information is true and accurate to the best of my knowledge Signed

This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow, Microblading, semi-permanent makeup application. If you have any questions, please don't hesitate to ask.

Although 3D Eyebrow Microblading is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure

This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent, it is considered a permanent marking.

All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after use. Cross contamination guidelines are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual and advised to expect a Touch-Up after healing is completed.

Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time. Additional Touch-Ups are likely needed within 6 months to 2 years.

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Possible Risks, Hazards, or Complications

Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others. Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See "After Care" sheet for instruction

Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven

Asymmetry: Every effort will be made to avoid asymmetry, but out faces our not symmetrical so adjustments may be needed during the follow-up session to correct

Excessive Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don't bruise or swell at all. Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now. MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your MRI Technician of any tattoos or permanent

Allergic Reaction: Although an allergy is unusual, there is always a possibility of an unknown allergy to the pigments and materials used during procedure.

The alternative to these possibilities is to use traditional cosmetic and NOT undergo the Semi-Permanent Eyebrow procedure.

Statement of Consent and Recitals: Please read and initial all lines

I understand that a certain amount of discomfort is associated with this procedure, and that

swelling, redness and bruising may occur.

I understand that although the European technique performed correctly, is considered semi- permanent since it fades and exfoliates out with the skin over time, strokes and markings are

considered permanent by nature and by the Health Department

I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.

I acknowledge that the proposed procedures(s involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention, hyper-pigmentation, scarring, bleeding, & nerve damage.

I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Touch- ups must be completed within 60 days of initial procedure.

I have been quoted the cost of today's appointment, and the cost of the touch-up. Touch-ups must be completed within 60 days of initial procedure to be considered a touch-up price.

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(s) I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material , and given to me, and I authorize as my Eyebrow Microblading technician(s) to perform on my body the 3D Eyebrow Microstroking procedure desired today.

Microblading Aftercare Instructions

Day One (Day of treatment): Wait 1-2 hours and let the wounds weep lymph. After 2

hours you must wipe off the lymph with a moistened cotton pad, then apply a thin layer pf

Aquahor with a cotton swab. Do this every hour on the hour until bed.

At night wash the treated area with warm water and mild soap like Cetaphil. Wash your hands with a disinfectant soap before washing your eyebrows and/or applying the post-

NOTE: Too much Aquaphor will cause the pigment to scab. Aquaphor is available in the skin care section of any drug store.

Day Two - Nine: Repeat the wiping of the brows at least 2 times a day. At night wash the treated area with warm water and mild soap like Cetaphil. Wash your hands with a disinfectant soap before washing your eyebrows and/or applying the post-care cream.

The following must be avoided during all nine days post-microblading procedure:

Sweating. It is recommended not to sweat for the first 10 days after the procedure. Sweat is salt and can prematurely fade the treated area. Practicing sports Swimming Hot sauna, hot bath, or Jacuzzi Sun tanning or salon tanning. Absolutely No Sun, sweating, or tanning prior to the procedure or after the procedure for 2 weeks. Do not have a tan/sunburn on your face prior to your procedure. The tan will exfoliate taking color with it as it fades. Any laser or chemical treatments or peelings, and/or any creams containing Retin-A or Glycolic Acid on the face or neck Picking, peeling, or scratching of the micro pigmented area in order to avoid scarring of the area or removal of the pigment Performing tasks related to heavy household cleaning such as garage or basement cleaning where there is a lot of airborne debris Spicy foods Smoking Drinking alcohol in excess, as it may lead to slow healing of wounds Driving in open air vehicles such as convertibles, boats, bicycles, or motorcycles Touching of the eyebrow area except for when rinsing and applying the post-care

Before showering apply a layer of post-care cream to protect your eyebrows from moisture. During the shower keep your face away from the showerhead.

Itching and flaking may appear during the first seven days post-microblading procedure. However, experience has shown that by following these after-care instructions, these symptoms may quickly disappear.

The healing of deeper wounds might last between 14-21 days. Touch-ups and/or correction of the shape-design is recommended only after this period.

If you have any unexpected problems with the healing of the skin, please contact immediately, to discuss further instructions. can be reached on his/her cell phone:

At the first sign of infection, allergic or adverse reaction, consult with a health care practitioner and report to the Texas Department of State Health Services, Drugs, & Medical Devices Group at 1-888-839-6676

What to expect during and after your microblading session

Your new temporary eyebrow will go through several phases during the healing cycle.

The pigment will appear very sharp and dark immediately after the procedure. This is because the pigment is still sitting on top of your skin, and has not yet settled in completely. The color of the pigment will soften gradually. Do not be alarmed if you see some pigment on the cotton swab, as this is excess pigment and/or body fluid that is naturally exiting your skin.

Once the healing of the skin starts taking place, it will look like dandruff flakes or dry skin. This might give you the impression that the color pigment is fading too quickly, however, this is just superficial color and dry skin being naturally removed from your eyebrows.

Once completely healed, after 2 weeks, always apply a layer of sunscreen SPF 30 up to SPF 50 on your eyebrows when exposed to the sun. Sun exposure might cause the color pigment to fade away more quickly.

You can now enjoy your beautiful new temporary eyebrows. You will simply love your new gorgeous fresh look!