CONSENT FORM

Date*

Date

Name*

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The nature and method of the proposed semi-permanent makeup (Microblading, Combo Brows, Ombre & Powder Brows) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur.

By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:

I acknowledge that the following touch up is ONLY included 4 to 6 weeks after the initial session. If it exceeds 6 weeks it will be $175 for the following touch up.

I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.

I acknowledge that complications as a result of semi-permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.

I realize that my body is unique and HAYLEY STPIERRE COSMETIC STUDIO can not predict how my skin may react as a result of the procedure.

I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results.

I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.

I acknowledge that obtaining the semi-permanent makeup is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of HAYLEY STPIERRE COSMETIC STUDIO reasonably necessary to perform the procedure.

I understand that I will have the opportunity to approve the design and color of the semi-permanent makeup to be applied, and I accept responsibility for same.

I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my semi-permanent makeup, and that I must inform any future service provider that I have had micro blading applied. I understand and accept that such changes are not the fault of HAYLEY STPIERRE COSMETIC STUDIO. I further understand that such changes or degradation in my appearance may not be correctable through further semi-permanent makeup procedures.

I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for the internal use of HAYLEY STPIERRE COSMETIC STUDIO.

I consent to HAYLEY STPIERRE COSMETIC STUDIO using “before & after” photos of me for marketing purposes to display its capabilities and results.

I have been given the full opportunity to ask any and all questions which I might have about obtaining semi-permanent microblading procedures from HAYLEY STPIERRE COSMETIC STUDIO, and that all of my questions have been answered to my full and total satisfaction.

I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.

If I have previously had micropigmentation performed by someone other than HAYLEY STPIERRE COSMETIC STUDIO on the same area that I am asking HAYLEY STPIERRE COSMETIC STUDIO to work on today, I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which HAYLEY STPIERRE COSMETIC STUDIO has no control.

I understand that additional appointments after the initial and followup appointments may be required, and will be billed at HAYLEY STPIERRE COSMETIC STUDIO standard rates.

I understand that HAYLEY STPIERRE COSMETIC STUDIO can not predict the results in advance and can not guarantee and has not represented that the results will be as I desire.

I understand and fully accept the risks associated with this procedure and hold HAYLEY STPIERRE COSMETIC STUDIO harmless from same.

I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself.

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