BROW PATCH CONSENT FORM

Client Name*

First NameLast Name

Date Of Birth*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

2 weeks before your appointment - avoid botox and extreme sunbathing. 1 week before your appointment - avoid chemical peels, harsh facials, retinol, BHAS+AHAS exfoliators. 48 hours before your appointment - avoid drinking alcohol, avoid asprin, and ibuprofen. Day of appointment - Please arrive in comfortable clothing, you are more than welcome to bring a blanket to your appointment to stay warm. Due to sanitation reasons with tattooing I can not provide blankets. Guests and children are not permitted during the service. Eat a small meal and stay hydrated.

I understand pre care instructions.

Please upload 3 mandatory photos of your brows for assessment before your scheduled brow procedure.

A Brow Patch (mini microblade) will be a lighter coverage procedure to fill any gaps or patchy areas throughout both brows. In total this service will be 50% coverage. This service will not include a touchup. This service is not considered a full microblade session.

Please follow the following guidelines: Photos must be taken in good lighting. Photos can not be blurry, brow region must be able to be seen sharply. Photos must be taken with no makeup throughout brows.

1 photo of left brow. *

1 photo of right brow. *

1 photo of both brows head on. *

Please leave a brief description of what areas of concern require a brow patch. *

Reminder: This procedures purpose is to fill any gaps or patchy areas. This includes areas that lack hair. This service is not suitable for brows that have less than 50% of hair throughout brows (very very sparse brows). This service IS suitable for clients with thick brows or even thin brows that just need an extra enhancing to specific areas. Microblading strokes are nano hairstrokes that are hyper realistic and very natural and fade gradually over time.

You are encouraged to carefully review the information provided. By signing this form, you acknowledge, understand and agree to the terms, results, and information provided by this paperwork.

Cancellation/Reschedule Policy:

Appointments can only be rescheduled/canceled within 24 hours of the appointment time. Appointments that fail to be rescheduled within the 24 hour time frame will be required to pay 100% of the service total to reschedule their microblading appointment. Clients have full access to the booking site (vagaro) to reschedule at any date and time for their convenience to reschedule. In the event of a last minute cancellation, you will be charged 50% of the service total. Failure to pay cancellation fee will result in client no longer having access to book with licensed service provider.

No call/ No show Policy:

No call/ No shows are subject to charging card on file 100% of the procedure cost. No exceptions. Clients who fail to pay fee will no longer be able to book with licensed service provider.

Non-refundable deposit:

Deposits are required for microblading appointments to secure/reserve your allotted date/time of procedure. Deposits are non-refundable and go toward the total cost of your appointment. Thank you for being respectful of my time and business.

Procedure Disclosure:

1. Although, Microblading, Micropigmentation, and Microshading are effective in most cases, no guarantee can be made that a specific client will benefit from the procedure. Generally, the results are excellent, however skin texture, oiliness, scars, poor aftercare, previous procedures, etc. can all effect the way that your procedure heals and it is mportnat to understand that your results will alway vary per person.

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

3. Initially the color will appear more vibrant, bold and darker compared to the end result. Once the pigment has healed beneath the skin (usually within 3-7 days) the color will appear extremely light. And in some cases non-existent. As the skin is in the process of repairing itself, the true pigment color may not be visible for up tp 30 days. Once the healing process is fully complete (usually within 30 days) the color will appear 10-15% lighter than it did when fresh which will give a softer, natural looking appearance. Shrinkage is also common during the healing process. The following day your brows may appear thicker due to swelling, however strokes may shrink 5-10% once healed. It's important to note that semi-permanent tattoos heal beneath the dermal layer. The pigment is not above the skin. Uneven pigmentation can result from poor healing, improper aftercare, infection, or excessive bleeding during the appointment. This is completely different with everyone and can depend greatly on how you care for your new brows - even with the perfect aftercare, all skin may not retain the same.

4. For some clients this is a 2 part process and a follow up appointment can always be booked 8 weeks after the healing process IF necessary. Touch ups are meant to darken any healed pigment and intensify the strokes.

5. All instruments that enter the skin or encounter body fluids are disposable and are fully disposed after each use. Cross contamination guidelines are carefully adhered to.

6. A topical anesthetic will be applied to the treated area to help alleviate discomfort. Anesthetic work better on some people than others.

I have read and completely understand all that is written above about my procedure with Gabrielle Vega.

Please Sign Here*

Prior to booking, I have read the FAQ (Frequently Asked Questions) page located in my email & agree that I am a candidate for this procedure.*

First NameLast Name

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

First NameLast Name

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

First NameLast Name

I understand that this is a semi-permanent procedure and that the successful color saturation can NOT be guaranteed due to skin typing, hidden scar tissue, previous permanent makeup, or laser treatments.*

First NameLast Name

I understand that tattoos may cause MRI (magnetic resonance imaging) artifacts and that there may be a warming and/or tingling sensation in the permanent cosmetic procedure area during the MRI due to the iron oxide (metallic salts) properties of some pigments. It is understood that I should advise your physician that I do have permanent cosmetic (a tattoo) in the event that a MRI procedure is prescribed.*

First NameLast Name

I accept the responsibility to explain to you by desire for specific colors, shape, and position for any procedure done today prior to starting the procedure. I understand that when my outline box is drawn on - this is the time to make any changes. Once I accept the outline provided during my consultation, I am consenting to it.*

First NameLast Name

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.*

First NameLast Name

I acknowledge that the proposed procedure(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 and hyper-pigmentation.*

First NameLast Name

I have read and understand the aftercare paperwork provided to me & agree to follow all instructions. I understand that failure to follow the aftercare may results in poor pigment retention.*

First NameLast Name

I have read and understand the preparation instructions and guidelines provided to me in my confirmation email & agree to follow these steps prior to my appointment to allow for an easy session with optimal healing results.*

First NameLast Name

I understand this procedure does not always replace the need for makeup. In the case of a brow procedure - additional make-up may be required to give a bolder “glam” appearance.*

First NameLast Name

I have been quoted the cost of my appointment (pricing is located in your email or on my booking site)*

First NameLast Name

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. I understand that additional fees will apply to future appointments. *

First NameLast Name

I acknowledge that I am at least 18 years of age and I certify that I have read the contents of this form. I understand the risks and alternatives involved in this procedure. I understand the risks and alternatives involved in this procedure, which is why retention is not guaranteed. I have had the opportunity to ask questions, and all of my questions have been answered. I have reviewed Gabrielle Vega’s work & styling prior to booking my appointment and I do acknowledge all services are non-refundable. I acknowledge that I have reviewed and completely understand the material given to me, and I authorize Gabrielle Vega to perform my chosen procedure. *

First NameLast Name

In order to keep documentation of each client/procedure - before & after photos/videos will be taken. Client permission is required for posting any and all photos/videos publicly.

Yes, I give my consent for my before/after photos and videos to be shown on social media (Instagram/Facebook/Twitter/Etc.) and in printed materials. I agree that my full face may be displayed.

History of MRSA (Methicillin-resistant Staphylococcus Aureus?*

YESNO

Have you had Botox on or around your forehead/brow area within the last 3 weeks?*

YESNO

Do you have diabetes?*

YESNO

Hepatitis A B C D ?*

YESNO

Do you bleed easily?*

YESNO

Have you had surgical brow lift or face lift?*

YESNO

Alcoholism?*

YESNO

Abnormal Heart Condition?*

YESNO

Have you had a facial chemical peel in the last 4 weeks?*

YESNO

Are you currently pregnant or breastfeeding?*

YESNO

Are your brows tinted? Arriving to your appointment with tinted brows may affect the pigment chosen during your session?*

YESNO

Autoimmune disorder?*

YESNO

Do you have oily or combination skin?*

YESNO

Have or had Cancer?*

YESNO

Chemotherapy/Radiation within past 6 month?*

YESNO

Tan by booth, salon, or natural sunlight?*

YESNO

Tumors/Growth/Cysts present skin?*

YESNO

Difficulty numbing with dental work?*

YESNO

Taking blood thinners such as: Asprin, Ibuprofen, Alcohol, Fish Oil, Coumadin, etc.?*

YESNO

Have you previously had any tattoos or work done on the brow area? Including tattoos, microblading, microshading, soft tap?*

YESNO

Are you allergic to any of the following- Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Propylene, Glycol, Vitamin E Acetate, etc.?*

YESNO

Allergies to metals, food, etc?*

YESNO

Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy? (Only applies if you are using on forehead and near brows)*

YESNO

Accutane or acne treatment within the past 12 months?*

YESNO

Any diseases or disorders not listed?*

YESNO

Printed Name*

First NameLast Name

ARTIST SIGNATURE - ONCE REVIEWED

Pre Care Instructions

CLIENT CONSENT

Photo / Video Consent

Client Medical History Form