Informed​ ​Consent 

 

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
 
 
PROCEDURE(s):_________________

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:_________________
Microblading_​ ​informed_consent_and​ ​release1