This form provides information about microblading, and all permanent cosmetics which involves the application of semi- permanent make-up. You are encouraged to carefully review the information proved in order to make an informed decision as to whether to undergo the microblading procedure.
Microblading or permanent cosmetics involves the insertion of pigment into dermal layer of the skin and is a form of tattooing, Initially the color will appear more vibrant or darker compared to end result. Usually within 7 days the color will fade 40% - 70%, soften and look more natural. The pigment is semi-permanent and will fade over time will likely need to touched up within 12 months to 18 months.
All instrument the enter the skin or come into contact with bodily 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 realistic expectation. It is usual to expect a touch-up after the healing is completed.
Possible risk, hazards or complications:
● Pain: There is possibility of pain or discomfort even after the topical anesthesia has been used. Anesthetics work better on some than others.
● Infection: Although very rare, there is risk of an infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See the “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 correct any unevenness.
● Asymmetry: Every effort is made to avoid asymmetry but our faces not all symmetrical. Adjustments may be needed during the follow up sessions to correct unevenness.
● Excessive swelling or Bruising: Some people bruise and swell more than others. Ice packs may be helpful and the bruising and swelling typically disappears within 1-5 days. Some people don’t bruise or swell at all.
● Anesthesia: Topical anesthesia are used to numb the area tattooed. Lidocaine, Benzocaine, Tetracaine, and Epinephrine, in a cream or gel form is are typically used.
● Allergic Reaction: There is possibility of an allergic reaction to pigments or other materials used. You may take a 5-7 day patch test to determine this. Please initial to waive_______ or to do ________
Please read and initial all lines.
❏ I am not currently under the influence of drugs or alcohol.
❏ I am not pregnant.
❏ I do not currently nor have taken accutane within the last 12 months.
❏ I have not had botox and /or cosmetic fillers within the past two weeks.
❏ I have not had surgery of any kind within the past six months.
❏ I have not taken any blood thinning medications within the past 72hrs nor have I taken aspirin within the 24hrs.
❏ Aftercare instruction have been explained to me and are attached to this consent form. A written copy will given to me to for my reference, which I follow to best of my ability. If I have any questions I will call or email my technician.
❏ I have reviewed the Microblading and Cosmetics FAQ’s prior to my appointment, and I understand the information listed on there. ❏ I understand that there is a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.
❏ I understand that sun, tanning beds, pools, some skincare products and medications can affect my permanent makeup.
❏ I understand that Retin A, Renova, Tretinoin, AHA, and Glycolic Acids, must not be used on the treated areas. They will alter the color.
❏ I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done today.
❏ I understand that implanted pigment color can change or fade over time due to circumstances beyond anyone’s control and I will need to maintain the color with future applications and touch-ups session within 8-12
❏ I understand that the procedure involves inherent risk and that there is a possibility of one or more complication during and and/or following the procedures such as: infection, misplaced pigments, poor color retention, and hyper-pigmentation.
❏ I have been quoted the cost of today appointment which includes one (1) touch-up with the 4-12 weeks following today’s appointment. After the 12 week, a fee will apply for future touch-ups. There will be no refund for this elective procedure. Special Instructions for the technician: ___________________________________________ .
__________________________________________________________________________ I acknowledge that I am 18 years of age and I certify that I have read or have had read to me the contents of this form, I understand the risk and alternative involved in this procedure.
Informed Consent and Release
NO. OF VISITS REQUIRED: ________
TOTAL COST OF PROCEDURE(s): __________
I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s). X _____
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 materials given to me and I have authorized Nicole Johnson to perform cosmetic tattooing procedure on me. I hereby release Nicole Johnson, its employees and affiliates from any liability arising from any risks that are known, and or inherent to cosmetic procedures.
Client: ________________________________________________ Date:________________
Technician:_______________________________________________ Witness:__________________________________________________ Date:_________________
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