Beso Beauty School-Model Consent Form

Beso Beauty, LLC School for Microblading

3000 26th St. Ste A Metairie, LA 70002

504.518.4461

besobeautyschool@gmail.com

I *

authorize and permit students of Beso Beauty, LLC to perform the service of Microblading on myself.

I agree to the use and reproduction of pictures and statements of myself, used for advertising, publicity, brochures, as well as the Beso Beauty, LLC website or any other lawful purpose whatsoever in which, I may be included in whole or in part.

I hereby irreversibly release and forever discharge Beso Beauty, LLC, it's employees, representatives, and students from all and any liabilities from the service of Microblading as authorized in this consent form.

I warrant that I am of full age and have every right to contract in my own name and that I am fully familiar with the contents of this authorization and consent.

Signature*

Date*

Date

Print Name*

Pre-treatment Advice and Procedures

Delicate or sensitive skin areas may swell or redden, it is advised not to make social plans on the day of the procedure. Lip liner may appear "crusty" up to one week.

If unwanted hair is normally removed in the area to be treated, i.e., tweezing or waxing, the hair removal should be done at least 48 hours prior to your procedure. Do not resume any method of hair removal for two weeks following the procedure. Electrolysis should be avoided at least five days prior to the procedure.

Must refrain from dying eyelashes and/or eyebrows at least 48 hours before the procedure. Wait one week after the eyebrow or eyeliner procedure before dying lashes or brows.

If you wear contact lenses and are receiving eyeliner services, they must be removed during the procedure and should be replaced with a new pair. You should wait at least a day after the procedure to resume wearing contacts.

As a safety precaution, if you are receiving the eyeliner procedure, we recommend that you have someone accompany you that is able to drive you home if you so decide or if it is necessary.

If you are having lip liner done and have had previous problems with cold sores, fever blisters, or mouth ulcers, the procedure is likely to re-activate the problem. Your Permanent Cosmetic Technician can make recommendations to help prevent or minimize the outbreak. If you have visible sores, blisters, or ulcers on the day of the procedures we be unable to perform services.

Do not use aspirin or ibuprofen for 7 days prior to your procedure.

There must be a month between Dysport, Botox, or filler injections and permanent cosmetic services.

, as a model for Beso Beauty School have requested that you describe the procedure SO that I may make an informed decision whether or not to undergo the procedure.

You have described the recommended procedure to be used as Micro Pigmentation, the process of implanting micro- insertions of pigment into the epidermal layer of skin.

I voluntarily request that Beso Beauty School Student my permanent cosmetic technician to perform on my body the following procedure:Service Description: Eyebrow Microblading

Service Description

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an me better informed. I acknowledge that I may give or withhold my consent for this procedure.*

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed. I acknowledge that I may give or withhold my consent for this procedure.

I have informed Beso Beauty, LLC student(s) that I am in good health and I am not under the care of any Only fill out this bottom portion if you are under the care of a physician for a serious medical

Condition being treated

Physician's Name

Phone Number

Format: (000) 000-0000.

City

State

Zip

- Hyperpigmentation: is the darkening of an area of skin caused by increased melanin. - Corneal Abrasion: is a scratch on the eye's cornea. The cornea is the clear, protective covering over the iris.

I understand that allergic reactions to pigment are very rare, however, are possible.*

I understand that this procedure will involve pain and discomfort*

I understand the markings are permanent and that there is a possibility of hyperpigmentation resulting procedure, especially in individuals prone to hyperpigmentation from a scar or other injury.*

I understand the markings are permanent and that there is a possibility of hyperpigmentation resulting from a procedure, especially in individuals prone to hyperpigmentation from a scar or other injury.

I understand that a follow up procedure may be required.*

Other risks involved with the procedure may include, but not limited to: infections, allergic and other applied pigments, allergic and other reaction(s) to products applied during and after the procedure, spreading of pigment (pigment migration), fading of color and other unknown risks.*

Other risks involved with the procedure may include, but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction(s) to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.

I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may event I need to seek treatment(s) for any known or unknown reason associated with the procedure me.*

Iaccept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with the procedure planned for me.

I have been given an opportunity to ask questions about the procedures and the procedure to be used and hazards involved and I believe that I have sufficient information to give this informed consent.*

I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.

I certify this form has been fully explained to me and I have read it or it has been read to me. I contents.*

I certify this form has been fully explained to me and I have read it or it has been read to me. I

I have read the Post Procedure Instructions (pages 8 9) and understand that I will receive a physical verbal instruction immediately following the procedure.*

I have read the Post Procedure Instructions (pages 8-9) and understand that I will receive a physical copy along with verbal instructions immediately following the procedure.

I understand that there may be some pain involved during the procedure. Each person has a different and pain felt will be according to each individual's pain threshold.*

I understand that there may be some pain involved during the procedure. Each person has a different tolerance level and pain felt will be according to each individual's pain threshold.

I understand that other adverse side effects, although rare, can include swelling, temporary minor and pinkness, and soreness.*

I understand that other adverse side effects, although rare, can include swelling, temporary minor

bleeding, redness and pinkness, and soreness.

I understand that there will be some fading of color. (Fading occurs more frequently to those with oily technician has not guaranteed me as to how much color will stay.*

I understand that there will be some fading of color. (Fading occurs more frequently to those with oily skin The technician has not guaranteed me as to how much color will stay.

I understand that Permanent Makeup is a process and often requires several touch up applications. I that two or more applications of color (touch ups) may be necessary to receive the desired outcome. Appointment is an additional cost of ranging from $200.00-$500.00 if I choose to continue treatment with Beso depending on time and Artist choosen.*

I understand that Permanent Makeup is a process and often requires several touch-up applications. I also understand that two or more applications of color (touch-ups) may be necessary to receive the desired outcome. Each touch-up appointment is an additional cost of $200.00 if I choose to continue treatment with Beso.

I accept full responsibility for the color and shape of each and every procedure I receive. I take full for my eyebrows in regards to shape, color, and placement. I take full responsibility for the color and lips. I understand that the Microblading Technician/Student will review everything pertaining to this they begin.*

I accept full responsibility for the color and shape of each and every procedure I receive. I take full responsibility for my eyebrows in regards to shape, color, and placement. I take full responsibility for the color and shape of my lips. I understand that the Microblading Technician/Studen will review everything pertaining to this procedure before they begin.

CAUTION THERE MAY BE RISKS ASSOCIATED WITH THE PROCEDURE OF COMMERCIAL BODY ART, WHICH INCLUDES

PERMANENT TATTOOS, BODY PIERCING, AND PERMANENT COSMETIC APPLICATION, THAT MAY ADVERSELY AFFECT THE

HEALING PROCESS IF YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING CONDITIONS:

TO SOAP, DISINFECTANTS, ETC., HISTORY OF ALLERGIES OR ADVERSE REACTIONS TO PIGMENTS, DYES, OR OTHER SKIN

SENSITIVITIES, HISTORY OF EPILEPSY, SEIZURES, FAINTING, OR NARCOLEPSY, PREGNANCY OR BREAST-

FEEDING/NURSING, IMMUNE DISORDERS, OR SCARRING (KELOID

Signature*

Today's Date*

Date

Birth Date*

Date

Name*

Zip*

City*

Occupation

Address & Phone No.*

Format: (000) 000-0000.

Are you currently taking any medication? If yes, is it considered a blood thinner? Please explain*

Do any facial products you use contain RetinA and/or Glycolic Acid?

If YES, please refrain from using these products for at least a month after the procedure.

List any drug, makeup, skin or food allergies (i.e., soaps or cleansing creams, pigments or dyes)

Have you recently undergone a skin peel?

Do you have or have you ever had any of the following conditions? (MUST ANSWER YES or NO):

Abnormal Heart Condition*

Cold Sores*

Hemophilia (bleeding)*

Visual Disturbances*

High or Low Blood Pressure*

Scarring (Keloid)*

Tumors/Growths/Cysts*

Circulatory Problems*

Chemotherapy/Radiation*

Epilepsy*

Are you pregnant?*

Narcolepsy*

Breast feeding/nursing*

Diabetes*

Hepatitis*

Fainting Spells/dizziness*

Do you use tobacco products?*

History of skin lesions*

Seizures*

History of skin diseases*

Glaucoma*

Immune Disorders*

Have you ever experienced hyperpigmentation from an injury?

Are you currently taking aspirin or ibuprofen?

Do you have a history of cancer? If Yes, When?

Are you currently receiving chemotherapy or radiation treatments?

Examining Physician

**Beso Beauty, LLC student(s) shall not perform services on a person who is inebriated or incapacitated by the use of alcohol or drugs. Services will not be performed on persons with sunburn or other skin diseases or disorders (i.e., open lesions, rashes, wounds, punctured skin), psoriasis, or eczema present in the treatment area.

Signature

**You will receive a copy of post procedure instructions after your procedure is complete.

Properly cleaning the treated area is essential for retaining pigment and preventing infection. If treated area

is not continuously cleaned dead skin will build up, producing hard scabs causing rapid pigment loss.

Before cleansing thoroughly wash and dry hands. Use fingertips to gently clean treated area twice a day with a soft anti bacterial soap. *(Recommended Cleansers: Cetaphil, Johnson's hypo allergenic baby wash, Dial Foaming Anti Bacterial soap).

Before cleansing thoroughly wash and dry hands. Use fingertips to gently clean treated area twice a day with a soft anti-bacterial soap. *(Recommended Cleansers: Cetaphil, Johnson's hypo-allergenic baby wash, Dial Foaming Anti-Bacterial soap

After you have gently cleansed the intradermal cosmetic area with a mild antibacterial soap or coconut oil, use your fingertips to rinse with water and lightly pat the area dry.

Do not rub or pick at the epithelial crust; allow dead skin to flake off naturally. Absolutely no scrubbing, exfoliates, cleansing creams, or harsh chemicals.

Do not rub or pick at the epithelial crust; allow dead skin to flake off naturally. Absolutely no scrubbing,

Apply A&D ointment, Hustle Butter, or coconut oil sparingly twice DAILY after cleaning until the procedure area has healed. Use a clean cotton swab to carefully blot ointment; do not use your fingertips.

Do not expose treated area to water pressure in the shower. DO NOT clean treated area during or directly after bathing. Heat from water or steam helps to relax and cleanse pores making skin prone to pigment loss. Wait at least an hour and a half after bathing to clean treated area or clean before bathing.

Do not soak treated area in bath, swimming pool or hot tub. Do not swim in fresh, salt or chlorinated pool water. Refrain from spray tans, tanning beds, and high impact activities for two weeks or until completely healed. If high impact activities cannot be avoided use a sweat band to absorb perspiration.

Do not soak treated area in bath, swimming pool or hot tub. Do not swim in fresh, salt or chlorinated pool

Do not expose treated area to direct sunlight.

Facial sun block may be used after the procedure area has completely healed to prevent future fading of pigment color. (*Only for those frequently exposed to the sun)

Avoid using sponges and makeup brushes while healing. If necessary, use clean fingertips to apply makeup,Avoid sleeping on treated area while healing. If it is uncomfortable or difficult to refrain from sleeping on the area, use the Tegaderm Film. *Tegaderm film can be found at most drug stores in the Band-Aid aisle.

you are a blood donor, do not donate for l year following your procedure. (American Red Cross guidelines)

If you are a blood donor, do not donate for l year following your procedure. (American Red Cross guidelines)

Failure to follow post-treatment instructions may cause loss of pigment, discoloration, or infection. Remember, colors appear brighter and more sharply defined immediately following the procedure. As healing progresses, color will lighten up to 30 - 70%. A follow-up/re-touch procedure may or may not be needed. You are more than welcomed to ask for your artist contact information. If you would like to continue treamtment with Beso's company, your follow-up will be $200, NO EXCEPTIONS. Additional fees will apply for any and all appointments following the first procedure. Color boost are necessary in 6-9 months following the initial procedure to maintain color. Pricing is determined on a person by person basis at the discretion of the Microblading technician.

FOR YOUR CONVENIENCE, CAREFULLY AND THOROUGHLY READ THIS MODEL COPY IN ITS ENTIRETY TO ENSURE PROPER KNOWLEDGE OF POST PROCEDURE AFTER-CARE.

WARNING: In the event of an allergic reaction, infection, or abnormal inflammation/ swelling please immediately seek emergency medical care or call 911.

Enjoy your permanent cosmetics!

Date

Fees $50.00*

Procedure Requested

Area of Concern

Pigment(s) Expiration

Pigment(s) Used

Lot #

Anesthetic Used

Needle(s) Used

Procedure Started at

Procedure Ended at

Referred by

Touch up(s) Done on

A valid driver's license or state issued photo ID must be presented before receiving services. A copy of the driver's license or photo ID will be taken and attached to the completed consent form. These documents will be kept for reference in the client's file. All information obtained on this form is consider confidential and private and is used solely by the technician to provide the best service and

A valid the consider

make the most informed decisions.

Models Must Agree to the Client Photo Release

I hereby authorize Beso Beauty, LLC student(s) to take photographs of the work*

performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.

MODEL SIGNATURE*

Date*

Please keep in mind that the following listed will play a huge part in the way your results appear after you're

Heart Conditions/Pace laker/Defibrillator (No exceptions)

li you are any of these medications, you will bleed and the pigment may not retain

Triflusal (Disgren) Clopidogrel (Plavix) Prasugrel (Effient) Ticagrelor (Brilinta) Ticlopidine (Ticlid) Cilostazol (Pletal) Vorapaxar (Zontivity) Dipyridamole (Persantine Coumadin) Pradaxia (dibigatran) Xarelto (rivaraxaban) Eliquis (apixaban) Savaysa (edoxaban)

Shingles (No exceptions) If you've ever had Shingles on your face, Microblading will not be performed, as the procedure could cause a flare up

Eczema, Psoriasis or Dermatitis in or around the brow area

Constant flaking/itching/irritation/shedding of skin

Oily or severely oily skin The hair strokes will appear more blended, solid or not retain as much

Large pores on your forehead & in the brow area Pigment will blur/blend in large pores looking powdered

Hemophilia-Bleeding Disorder Pigment may not retain

Ii you have hot flashes during the procedure, the pigment may not retain and the Microblading technician may have to stop the procedure

Platelet Disorders - Aggregation Disorders

An aggregation disorder is when platelets do not bind with fibrinogen and other proteins in order to stick to other platelets. As a result the platelets cannot form a plug to stop the bleeding from a damaged blood vessel.

Moles/Skin Tags in or around the brow area Pigment will not be put into anything raised.

Piercing in the brow area Scars can cause the pigment to migrate

Deep wrinkles in the brow area The hair strokes will not lay properly in the creases, giving the brow an uneven look

Thyroid condition and taking medication for this condition Hypo, Hyper Thyroidism, Graves Disease, Hashimotos

Fitzpatrick Skin types l (red heads/white skin/light eyes) Due to hypersensitivity the skin may not take the pigment well.

On Accutane (acne medicine) within the last 6 months

Auto Immune Disorder of any kind (MSRA, Lupus, HIV/AIDS or the like) Due to the medicines to treat these diseases, pigment will not retain (No exceptions for MRSA, can be highly contagious)

Extremely Thin skin Transparent or Translucent or very vascular

Frequent Exercise Due to the frequent production of sweat(salt), the pigment WILL NOT retain, fade very quickly, appear blurred or change in color

If you work out regularly (5-7 days a week), your eyebrows WILL fade very fast due to the production of salt/sweat. Salt is used to remove permanent makeup. They WILL appear more powdered or blurred under the skin as well. Microblading Techs reserves the right to refuse future services if she feels the results won't be to the clients satisfaction.

ABSOLUTELY NO SUN 30 DAYS AFTER (This means you cannot go out in sun with a hat and glasses on, this means no SUN or HEAT FOR 30 days at all) If you resume tanning, the results will fade quickly, heal darker, or not retain at all

CONSENT & RELEASE

DIABETES, HISTORY OF HEMOPHILIA (BLEEDING), HISTORY OF SKIN DISEASES, SKIN LESIONS OR SKIN SENSITIVITIES