Form costumer - Microblading in Arizona

Name
First Last
Date
Date Format: MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Email
Date of Birth
Date Format: MM slash DD slash YYYY
Emergency contact
Phone

Consent
Consent and Release Agreement for Permanent Cosmetics

This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetics application. If you have questions, please don‘t hesitate to ask. Although permanent cosmetic tattooing 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 sealed and sterilized before use 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 5-7 days the color will fade 10-50%, soften and look more natural. The pigment is permanent but will fade somewhat over time and will likely need to be touched-up through the years.

Photography Release Consent:
Insurance company requires “Before” and “After” photos be taken and kept on file. We would like your permission to use these photos, videos for advertising. Examples; in portfolios, online & in print ads. Your consent is necessary.

Please circle and indicate with your signature if you would like your photos/videos used or not used in advertising.

YES Feel free to use them / NO Please do not use them
I agree to the privacy policy.
Print Name
First Last
Signature
Date
Date Format: MM slash DD slash YYYY
Special requests, concerns, or remarks for the technician:

Consent
Possible risks, hazards, or complications:
- Pain:There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than others. Lip procedures are more likely to involve some pain.
- Infection: Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care” instructions sheet.
- Uneven Pigmentation: This can result from poor healing, infection, bleeding or many 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 or Bruising: Some people bruise and swell more than others. Ice packs may help reduce the bruising and the swelling which will typically disappear with 1-5 days. Some people don’t bruise or swell at all.
- Eye Exposure: There is a small risk of eye injury when an eyeliner procedure is performed. To avoid corneal abrasion; Celluvisc, a thick eye drop is used to protect the eye prior to the procedure. Eye drops are used to cleanse and flush the eye after the procedure is complete.
- 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 products, please inform your technician prior to the procedure.
- MRI: 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.
- Fever Blisters: If you are prone to cold sores or fever blisters (herpes simplex), there is a high probability that you will have an outbreak from the procedure. It is advised that you call your doctor for an antiviral prescription to help prevent this from occurring
- Allergic Reaction: There is a small possibility of an allergic reaction. You may take a 5-7 day patch test to determine this.
I agree to the privacy policy.
Please initial to receive patch test:
The alternative to these possibilities is to use topical cosmetics and not undergo the Permanent Cosmetics Procedure.
Consent and release Final for procedures performed
I express my complete satisfaction
Date
Date Format: MM slash DD slash YYYY
Signature

STATEMENT OF CONSENT AND RECITALS:
Please read and initial all lines:

1- 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 my technician.
2- I understand that a certain amount of discomfort is associated with this procedure and swelling, redness, and bruising may occur.
3- Fever blisters may occur in lip procedures in individuals who have the herpes simplex virus and it is my responsibility to obtain a prescription from my doctor for an anti-viral medication to help avoid a breakout.
4- I understand that Retin-A, Renova, Alpha Hydroxy, and Glycolic Acids must not be used on the treated areas. They will alter the color.
5- I understand that sun, tanning beds, pools, some skin care products, and medications can affect my permanent makeup.
6- I understand that successful lip color saturation can NOT be guaranteed due to hidden scar tissue.
7- I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m scheduled for an MRI.
8- I accept the responsibility to explain to you my desire for specific colors, shape, and position for any procedures done today.
9- I understand that implanted pigment colors 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 60 days.
10- 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.
11- I have been quoted the cost of today’s appointment. After 30 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, Samira Azish, as my permanent cosmetics technician to perform on my body the following procedures:
I read all of the above and I agree.
Procedure(s) desired today:
Signature and Date:
Witness Signature and Date:
Date
Date Format: MM slash DD slash YYYY

History Form

Step 1 of 5