MICROBLADING Consent

First Name *

Last Name *

Phone Number *

This form provides information about microblading, which involves the application of semi‐permanent makeup. You are encouraged to carefully review the information provided to make an informed decision as to whether to undergo the microblading procedure. Microblading involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing. Initially the color will appear 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 12 to 18 months. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are carefully adhered to. Generally, the results of microblading are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch‐up after the healing is completed. *

I UNDERSTAND

SERVICE PERFORMED TODAY *

MICROBLADING / EYEBROW

EYELINER

LIPSTICK

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. The alternative to these possibilities is to use cosmetics and not undergo the microblading procedure. Consent for Microblading Procedure: Please read and initial all lines. *

WAVE

TAKE

Lip Blush: The repeated needling in the sensitive area can cause a flare-up of the Herpes Simplex Type 1 virus which results in cold sores *

I understand

N/A

I am aware that the result of the procedure is determined by the following: Medication Skin Characteristics: Dry, Oily, Sun-Damaged Natural skin undertones Alcohol intake & smoking General stress A compromised immune system Poor diet Post procedure care treatment *

AGREE

I am currently not under the influence of any drugs or alcohol. *

NO

YES

I am not pregnant or breast feeding? *

NO

YES

Have you received any chemotherapy or radiation treatment in the last year? *

NO

YES

Prior to dental procedures do you receive antibiotic therapy? *

NO

YES

Do you have an MRI / IPL scheduled in the next 3 months? *

NO

YES

Do you Keloid Scar? *

NO

YES

Do you have transmittable blood conditions like HIV or hepatitis *

NO

YES

Do you have hemophilia *

NO

YES

Have you had a dental injection to numb your mouth that you had a reaction to? *

NO

YES

Have you engaged in excessive of any of the following in the last 2 days: Aspirin, Ibuprofen, Alcohol, Illegal Drugs? *

NO

YES

I do not currently, nor have I taken Accutane within the last 12 months. *

NO

YES

I have not had Botox and/or other cosmetic filler procedures within the past 2 weeks. *

NO

YES

I have not taken any blood thinning medication with the past 72 hours nor have I taken aspirin within the past 24 hours *

NO

YES

I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas as they will alter the color. *

I understand

I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. *

I understand

I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done today. My technician will adjust the brow shape until I are satisfied & verbally confirm the final shape with me before any procedure is implemented on my face. *

I accept

I understand that implanted pigment color can change or fade over time due to circumstances beyond the salon’s control. Immediately after the procedure the enhancement can be 40% - 60% darker than the desired result and can take 4-10 days to lighten. *

I understand

I will need to maintain the color with future applications and a touch‐up session within 6‐8 weeks. A touch up may not be necessary but it is recommended for best results *

I understand

I understand that non-toxic pigments are used during the procedure and are not approved by the Food and Drug administration (FDA) and the health effects are not known *

I understand

I have been quoted the cost of today’s appointment which includes todays procedure. We recommend a touch up within 6‐12 weeks following today’s appointment. *

Touch up cost *

For the purpose of documentation, I consent to the taking of “before” and “after” photographs my procedure & give consent to use said photos in B. Sweet print & online marketing efforts without compensation. *

You may use my photos

Please don't use my photos

I CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE ABOVE CONSENT FORM AND THAT I HAVE REQUESTED TO HAVE PERMANENT COSMETIC ENHANCEMENT OF MY OWN FREE WILL. *

Agree

I HAVE CAREFULLY CONSIDERED THE OUTCOME MAY NOT BE EXACTLY WHAT I IMAGINED BUT AM COMFORTABLE WITH THE POTENTIAL RISKS, VARIATIONS IN STROKE PATTERN & HEALING. *

Agree

NO REFUNDS WILL BE GIVEN AFTER PAYMENT IS RECEIVED. *

Agree

I WILL RECIEVE A COPY OF CARE INSTRUCTIONS AND WILL HAVE IT EXPLAINED TO ME AFTER THE APPOINTMENT. *

ok

I WILL RECIEVE A COPY OF CARE INSTRUCTIONS AND WILL HAVE IT EXPLAINED TO ME AFTER THE APPOINTMENT. *

ok

Are you allergic to any of the following? *

Please Sign *

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