PERMANENT MAKEUP CONSENT FORM

PERMANENT MAKEUP CONSENT FORM
NAME

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER
Please enter a valid phone number.
BEFORE PERMANENT MAKEUP:

4 WEEKS BEFORE:
- NO filler treatments, retinol, chemical, peels, microdermabrasion, exfoliation treatments, or AHA's
2 WEEKS BEFORE:
- NO botox
48 HOURS BEFORE:
- DO NOT consume alcohol, caffeine, blood thinners, or pain killers, and avoid working out
POSSIBLE RISKS, HAZARDS, OR COMPLICATIONS:
- PAIN: There can be pain even after topical anesthetic has been used.
- INFECTION: Infection is very unusual. 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 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 unevenness.
- EXCESSIVE SWELLING OR BRUISING: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears within 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.
- ALLERGIC REACTION: There is a possibility of an allergic reaction to the pigments or other materials used. You may 5-7 day patch test to determine this.
Do you presently have or previously had any of the following? CHECK ALL THAT APPLY.

History of MRSAForehead/Brow liftDiabetesFace liftAbnormal Heart ConditonChemical peelBrow tintingOily skinAccutane or acne treatmenttan by booth or suntaking blood thinnersbotoxHepatitis (A,B,C,D)Easy bleedingAlcoholismCurrently pregnant/breastfeedingAutoimmune disorderCancerChemotherapy/RadiationTumors/growths/cystsAllergic reaction to any medicationsAllergiesRetin-A, glycolic acid, or alpha hydroxyl
PERMANENT MAKEUP AFTERCARE:

FOR BROWS
- WASH BROWS MORNING AND NIGHT FOR 10 DAYS WITH LASH AND BLADE BROW CLEANSER.
- AFTER FOLLOWING YOUR CLEANSING AFTERCARE PROCESS, APPLY HEALING BALM, MORNING, AFTERNOON AND NIGHT FOR 10 DAYS TO ENSURE OPTIMAL RETENTION.
- RICE GRAIN SIZE AMOUNT WILL COVER BOTH BROWS.
- NO MAKEUP ON THEM FOR 10 DAYS
- NO DIRECT SUNLIGHT FOR 10 DAYS
- NO PICKING OR RUBBING SCABS
- NO SWEATING
- NO SUBMERGING IN WATER, POOLS, ETC.
- USE SUNSCREEN ON THEM ONCE THEY'RE HEALED
FOR FRECKLES
- CLIENTS MUST KEEP THEIR FACE DRY FOR AT LEAST 24 HOURS FOLLOWING THE INITIAL PROCEDURE. AFTER THE FIRST DAY, CLIENTS SHOULD ONLY WASH THEIR FACE WITH A VERY GENTLE SOAP. SKIN MOISTURISERS SHOULD BE NON-SCENTED AS ANY FRAGRANCED PRODUCTS MAY IRRITATE THE SKIN.
- CLIENTS MUST NOT EXFOLIATE THE TATTOOED AREA TOO MUCH. THE SCABS FORMED POST-TATTOO NEED TO FALL OFF ON THEIR OWN TERMS TO AVOID PATCHY RESULTS. TO ACHIEVE A SOFTER, MORE NATURAL LOOK, CLIENTS CAN GENTLY EXFOLIATE THE AREA APPROXIMATELY SEVEN TO TEN DAYS POST PROCEDURE.
- CLIENTS MUST AVOID APPLYING MAKEUP TO THE TATTOOED AREA FOR AROUND TEN DAYS.
- CLIENTS MUST NOT SOAK THE AREA FOR AT LEAST TEN DAYS. THIS MEANS SWIMMING, SAUNAS AND STEAM BATHS MUST BE AVOIDED, AS WELL AS EXCESSIVE SWEATING.
FOR LIP BLUSH
- 30 MINUTES AFTER YOUR PROCEDURE,YOUR BODY WILL RELEASE LYMPH FLUID. THIS IS NORMAL. THROUGHOUT THE FIRST DAY OF HEALING, USE AN ANTISEPTIC WIPE OR A COTTON ROUND WITH LUKEWARM WATER TO REMOVE THIS FLUID TO PREVENT SCABBING.
- REFRAIN FROM SOAKING YOUR LIPS IN WATER FOR 1 WEEK
- NO MAKEUP ON LIPS FOR 1 WEEK
- AVOID SAUNAS, SWIMMING, AND EXCESSIVE SWEATING
- MAKE SURE TO BRUSH YOUR TEETH WITH YOUR MOUTH WIDE-OPEN, TRYING TO AVOID ANY PASTE AND WATER FROM TOUCHING YOUR LIPS
- EAT CAREFULLY TO AVOID TOUCHING FOOD ONTO YOUR LIPS
- ALCOHOL, HOT AND COLORFUL DRINKS SHOULD BE CONSUMED THROUGH A STRAW ONLY
- DO NOT PEEL OR PICK ANY SCABS
- KEEP LIPS MOISTURIZED AT ALL TIMES WITH AQUAPHOR OR THE OINTMENT PROVIDED ONLY
PLEASE READ AND CHECK ALL THAT APPLY

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, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments. 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 microblading procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each indivudal’s reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent.I understand that there may be certain amount of discomfort or pain associated with the procedure and that other adverse side effects may include minor and temporary bleeding, bruising, redness or other discoloration and swelling. Secondary infection in the area of the procedure may occur, however if properly cared for, is rare.I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.I authorize my technician to obtain pre-procedural and post-procedural photos and give my technician permission to use such photos for publication and/or for teaching purposes, as they choose.I have informed my technician of any existing health problems.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 any questions, I will call/email my technician.I understand that sun, tanning beds, pools, some skin care products, and medications, can affect my permanent makeup.I understand that because pigments used in permanent cosmetic procedures contain iron oxide, there may be a warming/tingling sensation in the area of my procedure during an MRI, therefore I must advise my physician that I do have a cosmetic tattoo, in the event an MRI is prescribed.I accept the responsibility to explain fully to you my desire for specific colors, shapes, and positions for any procedure done today and that there is no refund policy.I have received pre- and post-procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.I accept full responsibility for the decision to have this cosmetic tattoo work done.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 and I have had the opportunity to ask questions and all of my questions have been answered.
SIGNATURE

Clear
DATE

MonthDayYear
Should be Empty: