Permanent Makeup Consent & Release Agreement
Microblading/softap eyebrows
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Embroidery Semi-permanent make up application. If you have questions, please don‘t hesitate to ask.Although 3D Eyebrow Embroidery (Microblading) is affective in most cases, no guarantee can be made that a specific client will benefit from the procedure.This is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing.All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are stickily adhered to.Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.Initially the color will appear much more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched-up within 6 months to 2 years. Do you understand?
Photography Release ConsentWe would like your permission to use these photos for advertising. For example, in portfolios, online and in print ads, etc. Your consent is necessary regarding this. Please select a choice to indicate if you would like your photos used or not.
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• Pain: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.• Infection: 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 “After Care” sheet for instructions on care.• Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance.• Asymmetry: 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.• Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-5 days. Some people don’t bruise or swell at all. • Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.• MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.• Allergic Reaction: There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7 day patch test to determine this. Please initial to: Waive____ or Take______.The alternative to these possibilities is to use cosmetics and not undergo the 3D Eyebrow Embroidery (Microblading) procedure.
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STATEMENT OF CONSENT AND RECITALS: Please read and sign at the bottom to agree with all lines .__Aftercare instructions have been explained to me and a 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.___I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.___I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color.___I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.___I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m schedule for an MRI.___I accept the responsibility for explain to you my desire for specific colors, shape, and position for any procedure done today.___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 within 60 days.___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.___I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s) and 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 said technician, as my Eyebrow Embroidery technician to perform on my body the 3D Eyebrow Embroidery procedure desired today.
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Client Medical History Form
Name
First Name
Last Name
Birthdate
Address
Emergency contact
Check mark if you have any of the following:
History of MRSA
Botox
Diabetes
Hepatitis
Forehead or brow lift
Easy bleeding
Face lift
Alcoholism
Heart condition
Recent Chemical peel
Pregnant or breastfeeding currently
Brow or lash tinting
Autoimmune disorder
Oily skin
Cancer
Acne treatment
Difficulty numbing
Taking blood thinners
Allergic to: lidocaine, epinephrine, tetracaine, dermacaine, benzyl alcohol, lecithin, aquaphor, vitamin e acetate
allergies to food or metal
any other diseases not listed
use skin care products: retin-A, glycolic acid, alpha hydroxyl..
Any other medical concerns or questions
Current medications or vitamins
I agree with all the above information that it is accurate to the best of my knowledge.
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Warning
Do Not use any Retin-A or Glycolic Acids in the brow area during or after healing! Do Not scrub or pick treated areas! Do Not expose area to the sun or tanning beds! Avoid swimming pool for 14 days! Do Not dye or tweeze eyebrows for one week after the procedure!
What is normal
• Mild swelling, itching, light scabbing, light bruising and dry tightness. Ice packs are nice relieffor 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 make adjustments during the touch up appointment.• Color change or color loss. As the procedure area heals, the color will lighten and sometimes seem to disappear in places. This can all be addressed during the touch up appointment which is why touch up is necessary. The procedure area has to heal completely before we can address any concerns. Healing takes about four weeks.• Need a touch up months later. A touch up 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 to 45 days after the first session; . Then every 6 months to 1 year to keep them looking fresh and beautiful. Future touch up sessions will cost the current touch up rate at the time you have it done. 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 and warnings:
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Month
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