Eyebrow Microblading Consent and Release Agreement
This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow Microblading 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 strictly 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.
Photography Release Consent
We 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 circle and indicate with your signature if you would like your photos used or not used in advertising.
YES, feel free to use them NO please do not use them
Date________________ Email: __________________________
Special requests, concerns or remarks for technician: ______________________________________________________________________________________________________________________________________________
Possible risks, hazards or complications
• 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.
Consent and release for procedures performed:Signed_____________________________________Date__________________
STATEMENT OF CONSENT AND RECITALS: Please read and initial 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 to 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 30-60 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 have been quoted the cost of today’s appointment which includes one (1) touch up after 30 days and within 60 days. After 60 days a fee will apply and there will be no refunds for this elective procedure(s). 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 Jessica Clark, as my Eyebrow Microblading technician to perform on my body the 3D Eyebrow Embroidery procedure desired today.
Client Medical History Form
Date___________ Birth Date_____________ Age______ DL or ID# _____________________ Name:__________________________________________________________Address:__________________________________City__________________ State______Zip______ Phone#________________________Email_____________________________Emergency contact:_____________________________ Phone#_____________________
Do you presently have or previously had any of the following: (Circle yes or no) Yes No History of MRSA
Yes No Botox (last treatment________)
Yes No Diabetes
Yes No Hepatitis (A,B,C,D)/HIV/AIDS
Yes No Forehead/Brow lift
Yes No Easy bleeding
Yes No Face lift
Yes No Alcoholism
Yes No Abnormal Heart Condition
Yes No Take meds before Dental work
Yes No Chemical Peel (last treatment________)
Yes No Pregnant now/ Breast feeding now
Yes No Brow or Lash tinting
Yes No Autoimmune Disorder
Yes No Oily Skin
Yes No Cancer year_____
Yes No Accutane or acne treatment
Yes No Chemotherapy/ Radiation
Yes No Tan by booth or sun
Yes No Tumors/ Growths/ Cysts/ Keloids
Yes No Difficulty numbing with dental work
Yes No Taking blood thinnners such as: Aspirin, Ibuprofen, alcohol, Coumadin, etc.
Yes No Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, etc. List_____________________________________________________________
Yes No Allergies to metals, food,etc.___________________________________________________
Yes No Any diseases or disorders not listed: ______________________________________________
Yes No Do you use skin care products containing Retin-A, glycolic acid or alpha hydroxyl?
Please list medication or vitamins you’re presently taking:___________________________________
I agree that all the above information is true and accurate to the best of my knowledge.
I have read, understand, and agree to the above instructions.