Paige's Place LLC consent

Paige's Place LLC consent

This form is designed to give information needed to make the decision to undergo this semi-permanent tattoo procedure. By completing this consent form, I understand that I have been informed of the risks and possibilities of infection and complications that may arise as a result of Microblading. I also have read the pre and post care instructions.
Full Name

First NameLast Name
DOB

MonthDayYear
Date
Photo copy of identification:

Cancelof
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
I understand that I cannot receive Botox or Dysport injections 2 weeks prior to my scheduled appointment
I understand that I cannot take antibiotics 2 weeks prior to and 2 weeks after my scheduled appointment.
I understand that I cannot receive laser treatments, chemical peels or microdermabrasion 2 weeks prior to my scheduled appointment.
I understand that I cannot use Retinol/AHA's and Vitamin C, 2 weeks prior to and after my scheduled appointment.
Please select any of the following that you have had or currently have:
If you selected Cancer/ Radiation, please provide the year of treatment:
Any diseases/disorders not listed?
Any allergies to metals, foods, etc?
I agree that all of the above information is true and accurate to the best of my knowledge.
Products and Equipment

To ensure the highest quality of safety, most of our tools are one time use only. ALL blades, wipes, and any other disposable products used during the procedure are discarded as biohazardous waste after each appointment, giving each client peace of mind. Any metal tools such as tweezers, scissors and microblading pens are places in a medical grade barbicide to be sterilized after each use to ensure the safety of both client and technician.
POLICIES
Touch-ups- Must be scheduled within 6-8 weeks. Any touch-up appointment outside of the 8 week window is then considered to be a regular touch-up ($300) If you cancel less than 24 hours or no show the touch-up is forfeited and you will be subject to a $100 late cancellation fee, with no exceptions.
New appointments- Failure to comply may result in forfeiture of your deposit, which then requires a new desposit to rebook.
Late Arrival - Arriving late deprives you of your valuable service time, and can also affect the appointment of guests arriving after you. If you are more than 15 minutes late, you may be asked to reschedule your appointment, which for new clients may result in forfeiture of your desposit.
Pricing - All purchases and services are final, and there are no refunds for this elective procedure.
Additional Treatments - An additional appointment may be necessary in order to achieve and complete the clients desired look. In these cases, additional touch-up fees will apply.
I have read, understand and agree to the policies stated above
Please initial
Photo Consent

I consent to and authorize the use of microblading photographs and/or videos taken by Paige’s Places LLC before, during, and after my microblading procedure. I understand that my identity will be protected and neither my full face or my name will be used in conjunction with any photographs and/or videos. It is understood that these images may be used by Paige’s Place LLC and social media accounts for demonstrational and promotional purposes.
I have read, understand and agree to the policies stated above.
Please initial
Possible Risks, Hazards, or Complications

Please read the statements below completely, and initial to indicate :
I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness, and bruising may occur. There may be discomfort even after the topical anesthetic has been used. Anesthtics work better on some people than on others.
I understand that although rare, there is a risk of infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See AFTERCARE instructions on care.
I understand that there is a chance of uneven pigment as a result of poor healing, infection, bleeding, and many other causes.Your touch-up appointment will likely correct any uneven appearance.
I understand that every effort will be made to avoid asymmetry, but our faces are not symmetrical, so adjustments may be needed during the follow up session to correct any unevenness.Your touch-up appointment will likely correct any uneven appearance.
I understand that successful color saturation CANNOT be guaranteed due to hidden scar tissue for clients.
I understand that Retin A, Renova, Alpha Hydroxy, and Glycolic Acids must not be used on treated areas as they will alter the color and cause premature fading.
I understand that it is my responsibilty to inform all skin care or medical personnel about my permanent makeup procedures, especially if I am aschedueld for an MRI. Pigments used in permanent cosmetic procedures contain inert oxides, and a low level magnet may be required if you need to be scanned by an MRI machine.
I understand that it is my responsibility to explain to you my desire for specific colors, shape, position for my microblading procedure.
I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond my control, and I may need to maintain the color with future appointments.
I understand that topical anesthetics are used to numb the area and it is my responsibility to inform you of any allergy to Lidocaine, Prilocaine, Benzocaine and/or any other epinephrine cream or liquid.
I certify that I have read the contents of this form and I understand the risks and possibility of complications. The alternative to this procedure is to use traditional cosmetics and NOT undergo Microblading.
I acknowledge that I have reviewed and approve of the above material, and I authorize Paige’s Place LLC to perform Microblading.
Should be Empty:

Paige's Place LLC consent

Products and Equipment

POLICIES

Photo Consent

Possible Risks, Hazards, or Complications

I certify that I have read the contents of this form and I understand the risks and possibility of complications. The alternative to this procedure is to use traditional cosmetics and NOT undergo Microblading.