Microblading Consent Form

Lip Blushing Consent Form

Statement of Consent and Recitals
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
SKIN TYPE: Review the Fitzpatrick Scale skin types below and check the one that best describes your skin. This information will help your technician determine the most appropriate way to approach your treatment(s):*

I. Very fair skin; blonde or red hair; light-colored eyes; freckles commonII. Fair skinned; light hair, light eyesIII. Very common skin type; fair; eye and hair color varyIV. Mediterranean Caucasian skin; medium to heavy pigmentationV. Mideastern skin; rarely sun sensitiveVI. Black skin, rarely sun sensitive
TECHNICIAN: Brianna Savoy (Licensed Esthetician/Commercial Body Artist-Studio B)

PROCEDURE: Lip Blushing

COST:
- Initial Appointment $400 (or discounted if specifically specified)
- 8-10 Week Touch-Up: $75
- Color Boost (withing 6-18 months after intial appoitnment): $200
I declare that I am over the age of 18, not under the influence of drugs or alcohol, not pregnant or nursing, not on blood thinners or blood pressure medication, and am not an insulin-dependent Diabetic. I understnad that many medication and some diseases and disorders may either contrindicate me for treatment or affect the results. I understand I should continue taking my medications, and tell my technicial about all prescription and non-prescription drugs, supplements, topically applied products, eye drops, etc. that I use or take. I understand permanent makeup is a tattoo process; it is not an exact science, but an art. I have been informed of the general nature of permaent makeup and the specific nature of the procedure(s) described above.

Risks of Procedure(s): I understand there are risks associated with permanent tmakeup, including, but not limited to: Infection: Procedures which involve penetrating the skin could cause infection; Scarring: Recovery from the procedure(s) could lead to scarring; Allergic Reaction: Pigments, dyes, or other materials used could cause a reaction; Color: Colors will vary based on skin tone, pigments may fade over time; Irregulatiry: Pigments may fan or spread, causing makeup lines; Corneal Abrasion: Rubbing or scratching eyes or appling contacts shortly after an eyeliner prcedure could cause an abrasion; Permanence: Permanent makeup is intered to produce long-lasting changes to apperance which may be difficult or impossible to modify or remove. Therefore, there will be no refunds once the procedure is completed.
Pigment Allergy Patch Test:*

I CONSENT to a patch testI WAIVE the patch test
(While an allergy patch test is recommended, it does not always accurately predict whether you will have a reaction. If waived, you release the technicial from liability if you then have an allergic reaction to the pigment.) If you do decide to get a patch test, you must come in atleast 24 hours before your appointment. If you do not schedule a time to come in 24 hours before your appointment, you must waive the patch test.
I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness, and bruising may occur. *
Initial
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. *
Initial
I understand that tanning beds, pools, and some skincare products and medication can affect my permanent makeup.*
Initla
I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. *
Initial
I well tell all skincare professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.*
Initial
I accept the responsibility to explain to you by desire for specific colors, shape and position for any procedure done. *
Initial
I understand that implanted pigment color can change and/or possibility of fading, fanning, spreading over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 70 days.*
Initial
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 70 days of initial procedure.*
Initial
I have been quoted the cost of today's appointment, and the cost of the touch-up. Touch-ups must be completed within 70 days of initial procedure to be considered a touch-up price. *
Initial
OTHER TREATMENT: I understand that if i have any skin treatments, including, but not limited to 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. *
Initial
PRE-PROCEDURE & AFTERCARE INSTRUCTIONS: I have received, and will strictly adhere to all pre-procedure and aftercare instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips. *
Initial
I certify that the consent has been fully explained to me, that I have read and initialed the above paragraphs, and that I elect to receive the permanent makeup procedure(s) indicated above. I understand the permanence of the procedure(s) as well as the possible complications and consequences of the 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 given to me, and I authorize Brianna Savoy (Licensed Esthetician and Commercial Body Artist) as my technician to perform on my body the procedure desired today. I consent to my photograph being taken before and after the procedure(s) for insurance purposes. *

Clear
RELEASE: In consideration for me being tattooed by Brianna Savoy, I hereby release the practitioner and/or any of the practitioners associated from any and all claims, which I may have now, or in the future arising from the tattooing process. I understand that the application of tattooing is artistic in nature and in all cases experimental and that no result can by guaranteed or certain. The tattooing process has been explained to be and I have been fully informed of the procedure(s) to be performed. I execute this release having read and fully understanding it, and do so completely voluntarily. *

Clear

Informed Consent

You WILL receive a copy of this information stated below!
WHAT TO EXPECT:
- DO NOT expect your lip tattoo to heal perfectly after the first session. This is a 2-step, sometimes multiple step, process.
- BE PATIENT during your healing process, your lips will change and appear different from the day of your initial appointment. THIS IS NORMAL. They may go through a "Disappearing Stage" where the color may seem to have all faded away. DO NOT WORRY. The skin is exfoliation and this is normal.
- Immediately after your procedure lips will appear darker and more defined. Normally after 5-7 days, it will fade 30%-50%. The color will slowly start to come back over the next 6-8 weeks. THIS IS NORMAL.
- Around days 3-4, you will experience scabbing and your lips may look dry and flaky. DO NOT PICK your scabs, let them fall off naturally. If scabbing comes off permanently, it may result in lack of pigment and cause patchy lips.
- Your lip tattoo will take up to 6-8 weeks to fully heal. When the flaking comes off the lip color may seem faint, this is because a fresh layer of skin has healed over the lip tattoo. Give your lips a few weeks and the pigment will become clearer.
- You may experience dryness on your lips. The aftercare ointment will help with this.
TOUCH UP:
- This is a 2-step process. The first session is used to start building up the pigment on the lips. The second session is used to perfect the lips and add more definition.
- The FIRST TOUCH UP or second session is done within the first 70 days after the first initial session. The fee for this is $75!
- It is your responsibility to book your touch up appointments, if your tattoo comes back to faded, additional charges may apply.
- Do not expect perfect results after the first session.
- Darker skin women, permanent makeup will not look as bold or sharp compared to lighter skin clients.
- Some client's skin may have a harder time retaining pigment and may require additional sessions.
LONG TERM CARE:
- THERE IS NO GUARANTEE OF RESULTS, everyone's results will very due to skin type, lifestyle, and the initial 7 day care and long term care of your lip tattoo.
- We suggest using at least SPF 50 to protect your lips when it direct sunlight. Sun exposure will cause fading and can alter the color of your tattoo.
- Do not use chemical exfoliants on the lips, this will cause lips to fade faster.
- As the tatooo fades the pigment will get fainter and less defined.
- Maintenance is required to maintian desired results. Touchups are done on average very 9-12 months to maintain your lip tattoo. The fee for a color boost/refesher after 6 months is $200.
- Lip blushing typically last 6m-3years.
I have read and fully understand this informed consent. *

Clear

Should be Empty:

Lip Blushing Consent Form

Informed Consent