Microblading / Microshading Touch-Up Consent

Microblading / Microshading Touch Up Consent Form

**Signature and Information Required Prior to Every Scheduled Appointment**
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date of Birth*

MonthDayYear
Age*
Cell phone *

Area CodePhone Number
Email*
example@example.com
Emergency Contact Person*
Phone Number*

Area CodePhone Number
MicrobladingMicroshadingPowder BrowsOmbre Brows
Within Six MonthsWithin One YearOver One Year
STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines.
I acknowledge that obtaining permanent make-up is my choice alone. Theapplication of permanent make-up will result in a permanent change to myappearance, and that needles and pigments will penetrate the surface of myskin. No representations have been madeto me as to the ability to later restore the skin involved in permanent make-upto the original condition, and it is very costly to remove.*

Clear
Aftercare instructions have been explained to me and 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 questions I will call or email you.*

Clear
I understand that a certain amount of discomfort id associated with this procedure and that swelling redness and bruising may occur.*

Clear
I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will after the color. *

Clear
I understand sun, tanning beds pools, some skincare products and medications can affect my permanent makeup.*

Clear
I understand sun, tanning beds pools, some skincare products and medications can affect my permanent makeup.*

Clear
I will tell skincare professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI.*

Clear
I accept the responsibility to explain to you my desire for specific colors, shape and position for any procedure done today. *

Clear
I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch up session after 4 weeks. *

Clear
I acknowledge that the proposed procedure(s) involve risks inherit in the procedure and have possibilities of complication during and or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.*

Clear
I have been quoted the cost of today’s appointment and will need to schedule a 4 weeks later for final brow touch-up to ensure the perfect brows an additional fee will apply and there are no refunds for this elective procedure(s).*

Clear
I understand that inks, dyes, and pigments have not been approved by the Federal Food and Drug Administration and that the health consequences of using these products are unknown.*

Clear
I accept responsibility for determining the color, shape and position of the enhancement as agreed during the course of my consultation.*

Clear
I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs.*

Clear
For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of said procedure(s). I give my consent for before and after pictures to be used for marketing.*

Clear
I am aware that the result of the procedure is determined by the following:Medication Skin Characteristics - i.e.dry/oily/sun-damaged Natural skin undertones, Alcohol intake and smoking,General stressA compromised immunesystem Poor diet, Post procedure care treatment. *

Clear
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved on this procedure(s) and have had the opportunity to ask all my questions, and all my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize (* ) as Eyebrow Embroidery technician to perform on my body the TOUCH UP Service procedure desired today.
I am over the age of 18 and I am not under the influence of drugs or alcohol.*

Clear
CLIENT SIGNATURE & DATE:*

Clear
Date*

MonthDayYear
Color Selected for client (to be added by Technician):
Lot or Model Numbers & Exp Date (to be added by Technician):
FAILURE TO FOLLOW AFTER-CARE INSRUCTIONS MAY RESULT IN INFECTINS, PIGMENT LOSS OR DISCOLORATION.

Cautions: If the skin around the eyebrows breaks out in a heat rash, small pimples, this usually a reaction to the numbing solution and should go away by itself in a couple weeks, don’t pick. Please call immediately if this occurs so a technician can make note of the reaction and follow up to ensure this is not a more serious situation.

FOR 7 TO 14 DAYS FOLLOWING PERMENANT COSMETICS PROCEDURES
- WARNING! DO NOT EXPOSE AREA TO THE SUN OR TANNING BEDS!
- No make-up, tinting or lashes or brows, sun, soap, sauna, Jacuzzi, swimming in chlorine pools or in the recreational bodies of water, contact with animals, gardening for 7-10 days, (until area is completely healed) post procedure and after all touch-ups.
- If you have excessive redness, swelling or tenderness or any red streaks going from the procedure site toward the heart, elevated temperature, or purulent drainage from the procedure site, contact your physician as the area may be infected and you may need to seek medical care.
- Avoid swimming pool for 14 days! Do not dye or tweeze eyebrows for one week after the procedure!
- Failure to follow post procedure instructions may result in infection or loss/discoloration of pigment.
WHAT IS NORMAL?
- Mild swelling, itching. Light scabbing, light bruising, and dry tightness. Ice packs are nice relief for swelling and bruising. Aftercare ointments work well for scabbing and tightness.
- Too dark and slightly uneven appearance. After 2-7 days the darkness will fade, and once any swelling dissipates unevenness usually disappears. If it is too dark or still a bit uneven after 4 weeks, then we will adjust during the touch up appointment.
- Color change or color loss. As the procedure area heals, the color will lighten and sometimes seems to disappear in places. This can all be addressed during the touch up appointment, which is why touch up is necessary. The procedure area must heal completely before we can address any concerns.
- Healing take on average four weeks.
- Need a touch up 1 month (4 weeks) later. A touchup may be needed 6 months to 1 year after the first touch up procedure depending on your skin, medications and sun exposure. We recommend the first touch up 30 days after the first session. Then every 1 year to keep them looking fresh and beautiful.
- Future touch up sessions is not included. If most of the hair strokes have faded, the entire procedure will need to be repeated. An email photo consultation may be necessary to determine if you need a touch up or a repeat of the entire procedure.
I have read, understand, and agree to the above instructions.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Microblading / Microshading Touch Up Consent Form