MICROBLADING (LIPS & EYELINER)
INTAKE & CONSENT FORM
How did you hear about us?
Do you presently or have previously had any of the following:
History of MRSA
BOTOX (Last Treatment:_______________ )
Abnormal Heart Condition
Chemical Peel (Last Treatment: )
Pregnant/Breast Feeding Now
Cancer (Year(s):_________ )
Accutane or Acne Treatment
Tanning (Booth or Sun)
Blood Thinners (Aspirin, Ibuprofen, Coumadin etc.)
Allergic Reaction to Medications (Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzoyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.)
Allergies (Metals, Food, Etc.)
Diseases or Disorders NOT listed Skin Products with (Retin A, Glycolic Acid, Alpha Hydroxyl) Please list Medications/Vitamins you’re taking
CLIENT PROCEDURE CONSENT
Please read and initial all lines:
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, Renova, Alpha Hydroxy and Glycolic Acids must NOT be used on the treated areas. They will alter the color of the tattooed area.
I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.
I understand that successful lip color saturation CANNOT be guaranteed due to hidden scar tissue.
I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m scheduled for a MRI.
I accept the responsibility to explain to my technician any desires for specific color, shape, and/or position for any procedure done today.
I understand that implanted pigment color may slightly change or fade over time due to circumstances beyond control and that I will need to maintain the color with future applications and a touch up session within 90 days.
I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have the possibilities of complications during and/or following the procedures such as infection, misplacement, pigmentation, poor color retention and hyper-pigmentation.
I have been quoted the cost of today’s appointment.
Consent Release Agreement
This form is designed to give information needed to make an informed choice of whether or not to undergo a Lip Blush Semi–Permanent make-up application. If you have questions, please do not hesitate to ask. Although Lip Blush is effective in most cases, no guaranteed 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; 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 common to expect touch-ups after 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 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.
Possible Risks / Hazards / Complications:
PAIN: There could be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.
INFECTIONS: Infection is very unusual. Less than a 0.25% of the population has an allergic reaction. The areas treated must be kept clean and only touched with freshly cleaned hands. You must follow the specific after care instructions provided to you.
UNEVEN PIGMENT: This can be a result of poor healing, infection, bleeding, or other causes. Your follow up appointment will likely correct any uneven appearances.
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/BRUISING: Some people bruise and swell more than others. Ice packs may help the bruising and swelling. It typically disappears within 1-5 days. Some people do not bruise or swell at all.
ANESTHESIA: Typical anesthetics are used for numbing the area to be tattooed. Lidocaine, Prilocaine, Benzonecaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform your technician immediately.
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 small possibility of an allergic reaction.
I agree to Stylus Beauty cancellation and etiquette policies.
Image Waiver Consent:
I agree to allow Stylus Beauty to use photographs that are taken of me, the client, during the procedure. These images may be posted online in association with the procedure, but my name will not be depicted or connected to my image.
Service(s) to be received by client during this session:
In case of emergency, contact: _______________________________________
It’s important to try not to get the tattoo wet during the healing process (5-7 days). Even though it is unlikely that the tattoo will remain dry for the entirety of the healing process, refrain from swimming or submerging the area in water for long periods of time for the first week of healing. Following this makeup tattoo aftercare procedure will ensure the formation of thin scabs thus more color retention. Keep out of the sun for 7 days after you get your tattoo.
• FOR LIPS ONLY: Use Aquaphor to keep the tattoo protected while it heals and to soothe any discomfort such as itching or dryness. Avoid applying lip balms, lipstick, or other lip products during this time. Apply Aquaphor every 30-60 minutes for the first week to keep lips from drying out.
• AVOID touching any tattooed area with your hands. Apply all recommended products with Q-tips ONLY. If the area must be touched with hands, make sure you thoroughly wash your hands before and after touching the tattooed area.
• Day 3-4: When the scab starts to appear, do not wipe- only dab until dry; you must be gentle! Do not pull off the scabs prematurely.
• Week 2 or 3: After the procedure is completely healed, you may go back to your regular cleansing and makeup routine. Avoid scrubbing the area. Use sun block after the procedure area is healed to protect from sun fading.
• Scrub, rub, or pick at the epithelial crust that forms. Allow it to flake off by itself. If it is removed before it is ready, the pigment underneath it can be pulled out.
• Use any makeup on the tattooed area for at least 7 days.
• Use any Retin-A, Glycol Acids, or Neosporin in the tattooed area during or after healing.
• Expose area to sun or tanning beds.
• Swim in a pool for 14 days after your procedure.
What is normal?
• Mild swelling, itching, light scabbing, light brushing and dry tightness. Ice packs are a nice relief for swelling and bruising. Aftercare ointments work well for scabbing and tightness.
• Too dark and slightly uneven appearance. After 2-7 days the darkness will fade, and once any swelling dissipates, unevenness usually disappears. Adjustments will be made during the touch-up appointment.
• Color change or color loss. As the procedure area heals, the color will lighten and sometimes seem to disappear in places. This can be addressed during the touch up appointment, which is why touch up appointments are necessary. The procedure area has to heal completely before we can address any concerns. Healing takes about 4 weeks.
• Need a touch up months later. A touch up may be needed 6 months to 1 year after the first touch up procedure depending on your skin, medications, and sun exposure. We recommend the first touch up 30 days after the first session, then every 6 months to 1 year to keep your tattoos looking fresh and beautiful! If most hair strokes have faded, the entire procedure will need to be repeated. An email photo consultation (or in person consolation) may be necessary to determine if you need a touch up or a repeat of the entire procedure.
If the skin around the tattooed area breaks into a heat rash, or small pimples, this is usually a reaction to the numbing solution and should go away on its own in a couple of weeks. Please do not pick at it! Call immediately if this occurs so a technician can make a note of the reaction and follow up to ensure this is not a more serious situation!
(Initial) I have read and understand the above aftercare instructions. If I have any questions or concerns regarding these instructions I will call____________________. I acknowledge that how I follow these aftercare instructions and my own body chemistry has a direct effect on the outcome and results of my treatment. Mandatory Treatment Service must be scheduled to retouch color or fading. The cost
of this service is _________________.
PERMANENT COSMETICS WAIVER AND RELEASE FORM
I authorize my semi-permanent cosmetics professional at ____________________________ to perform the permanent cosmetics procedure. The risks of the cosmetic procedure I have chosen have been disclosed to me. It has been represented to me that no guarantees, warranties, promises, commitments or other statements as to the results of this treatment have been made, and I acknowledge that I have received no particular representations or guarantees, and I am consenting to the procedure at my own risk. I have revealed or disclosed on the Medical Profile form all conditions and circumstances regarding my health and health history, medications being taken and any past reactions to products used or medications taken. Additional conditions could occur or be discovered during or after the procedure, which could affect my ability to tolerate the procedure.
I understand the success of my Permanent Cosmetics process requires my careful maintenance. I understand that I must strictly adhere to all aftercare instructions. I understand that failure to follow after-care instructions may result in infection, pigment loss, or discoloration. I agree to and understand all of the above information and consent that all of the information is correct to the best of my knowledge.
I, as herein signed, release, give up, acquit and discharge my semi-permanent
cosmetics professional and/or anyone affiliated with ___________________________ from any claims or damages of any nature. I agree to pay any costs of legal services necessary to further effect or confirm said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this waiver and release form, and said damages are specifically waived following the signing of this waiver and release form. I further agree to hold my semi-permanent cosmetics professional nameless and harmless from any and all damages. I release
my semi-permanent cosmetics professional from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure. I understand that I am responsible for any medical treatment I may need as a result of getting this procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the __________________________ procedure, which is to be performed at my request.
Please read the following statement and sign and date on the line to indicate that you have read, understand and accept the following statement:
I, the client herein signed, certify that I have read and had explained to me and fully understand the above waiver and release form. I certify that I have been consulted
with a semi-permanent cosmetics professional and have read all applicable literature given to me. I have completed the above forms to the best of my knowledge. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this waiver and release form for myself. I, the undersigned client, acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time. I, the client herein signed, for the purposes of documentation, hereby consent to “before and after” photographs, which may or may not be used for the purposes of advertising.
Client Signature: Date: ______________________________________________________
I understand and agree to the electronic signature consent information provided
Electronic Signature Consent:
By signing this form, I agree that my typed, electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.