Microblading Consent Form ContactName(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth Microblading DisclaimerAlthough Microblading is effective in most cases, no guarantee can be made that a specific guest will benefit from the procedure. This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semipermanent, it is considered a permanent marking. All instruments that enter the skin or meet with bodily fluids are sterile 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 and advised to expect a Touch-Up within 60 days after healing is completed. Initially, the color will appear more vibrant or darker compared to the result. Usually within 5-7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time. Additional Touch-Ups are likely needed within 6 months to 2 years.ContraindicationsI understand that this procedure is not recommended to proceed with the treatment if you have the following: History of MRSA Forehead / Brow Lift Abnormal Heart Condition Autoimmune disorder Pregnant / Breastfeeding Chemotherapy / Radiation Tumors / Growth / Cysts Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc. Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, etc. Allergies to metals, food, etc. Difficulty numbing with dental work Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc. Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, etc. Allergies to metals, food, etc.• Botox Date of last treatment• Chemical Peel Date of last treatment• Cancer Date of last treatment• Any other diseases or disorders not listed:• Please list your current medicationsDo you use skincare products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl? Yes No DisclosureAgreement(Required) I accept the following statements.• I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment. • I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness, and bruising may occur. • I understand that tanning beds, pools, some skincare products and medications can affect my permanent makeup. • I accept the responsibility to explain to my Esthetician my desire for specific colors, shape, and position for procedures done today. • I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Touch - ups must be completed within 60 days of initial procedure. • I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. • I acknowledge that I have not had dermal fillers or other injectables in the treated area in the last 10 - 14 days. • I acknowledge that if I am prone to Herpes, I have consulted my physician and I am taking an antiviral to reduce the chance of a breakout. I should avoid treatments during a breakout. • I acknowledge I must reveal any condition that may have a bearing on the procedure, such as pregnancy, allergies, facial waxing, medication use, diabetes or immune deficiencies, prior to receiving treatment. • I understand that I must always wear a sunscreen with a minimum SPF 50 while outdoors to avoid hyperpigmentation that may occur. • I understand that compliance to my post-care instructions will greatly affect my final result. I acknowledge my obligation to follow the written and spoken instructions covering my pre- and post-treatment care regimen. • I consent to photographs being taken to evaluate treatment. No photographs revealing my identity will be used without my written consent.Consent(Required) I agree to the notice.My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I hereby give consent to my Esthetician to perform a microblading treatment. I hold harmless LaVida Massage, my Esthetician, and affiliates of all circumstances that may occur during my treatment. By signing below, I acknowledge the information provided is true and correct to the best of my knowledge. I agree that I am willing to follow recommendations by my esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to sunscreen and avoiding the sun/tanning booths and extreme weather conditions. I agree to use a moisturizer specifically recommended by my Esthetician and I acknowledge that I have been informed of the possible negative reactions and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). If I may have additional questions or concerns regarding my treatment or suggested home product/posttreatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM: I AM 18 YEARS OF AGE OR OLDER. I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS. I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW. I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL. By signing below, I agree I have read and agree to the legal agreements above.Signature(Required)NameThis field is for validation purposes and should be left unchanged.
