Client Consent Form Microblading


Microblading Consent and Release Agreement

This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow, Microblading, semi-permanent makeup application. If you have any questions, please donโ€™t hesitate to ask. Although 3D Eyebrow Microblading is effective 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 basal layer of the epidermis. It is a form of tattooing, though semi-permanent.

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 usual and advised to expect a Touch-Up after healing is completed.

Initially the color will appear more vibrant or darker compared to the end 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.

Client Medical History Form

Name *
Name
Date *
Date
Birthday *
Birthday
Address *
Address
Phone *
Phone
Check below if you have or previously had any of the following:
Signature
* Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others. * Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See "After Care" sheet for instruction 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 any unevenness. *Excessive Swelling or Bruising: Some people bruise or swell more easily than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don't bruise or swell at all. *Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now. *MRI: Because pigments used in Permanent Cosmetic procedures contain inert oxides, a low level magnet may be required if you need to b scanned by an MRI machine. You must inform your MRI technician of any tattoos or permanent cosmetics. The alternative to these possibilities is to use traditional cosmetic and NOT undergo the Semi-Permanent Eyebrow procedure.
Today's Date *
Today's Date

Post Microblading

The following must be avoided during all nine days post-microblading procedure:

  • Increased sweating

  • Practicing sports

  • Swimming

  • Hot sauna, hot bath, or Jacuzzi

  • Sun tanning or salon tanning

  • Any laser or chemical treatments or peelings, and/or any creams containing Retin-A or Glycolic Acid on the face or neck

  • Picking, peeling, or scratching of the micro pigmented area in order to avoid scarring of the area or removal of the pigment

  • Performing tasks related to heavy household cleaning such as garage or basement cleaning where there is a lot of airborne debris

  • Spicy foods

  • Smoking

  • Drinking alcohol in excess, as it may lead to slow healing of wounds

  • Driving in open air vehicles such as convertibles, boats, bicycles, or motorcycles

  • Touching of the eyebrow area except for when rinsing and applying the post-care cream with a cotton swab

  • Before showering apply a layer or post-care cream to protect your eyebrows from moisture. During the shower keep your face away from the shower head

Itching and flaking may appear during the first seven days post-microblading procedure. However, experience has shown that by following these after-care instructions, these symptoms may quickly disappear.

The healing of deeper wounds might last between 14-21 days. Touch-ups and/or correction of the shape-design is recommended only after this period.

If you have any unexpected problems with the healing of the skin, please contact Luxe Lashes immediately to discuss further instructions.

Statement of Consent and Recitals:

Please read and check each box. *
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). 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 Arielle Davis, as my certified Eyebrow Microblading technician to perform on my body the 3D Eyebrow Microblading procedure desired today.
Today's Date
Today's Date

What to Expect During and After Your Microblading Session

Your new temporary eyebrow will go through several phases during the healing cycle.

The pigment will appear very sharp and dark immediately after the procedure. This is because the pigment is still sitting on top of your skin, and has not yet settled in completely. The color of the pigment will soften gradually. Do not be alarmed if you see some pigment on the cotton swab, as this is excess pigment and/or body fluid that is naturally exiting your skin.

Once the healing of the skin starts taking place, it will look like dandruff flakes or dry skin. This might give you the impression that the color pigment is fading too quickly, however, this is just superficial color and dry skin being naturally removed from your eyebrows.

Once completely healed, always apply a layer of sunscreen SPF 30 up to SPF 50 on your eyebrows when exposed to the sun. Sun exposure might cause the color pigment to fade away more quickly.

You can now enjoy your beautiful new eyebrows!

Name *
Name
We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Booking and Cancellation Policy

The following policy will be effective as of January 4, 2016:

A credit card will be required to be uploaded for all appointments. This information is secure and cannot be viewed by our staff. However, it will be charged through our online booking system in the event of a no-show or cancellation.

  • No-shows and any appointments cancelled within 24-hours of your appointment time will be charged 50% of the scheduled service price.

  • Re-lash appointments exceeding 3 weeks will be an additional $10 per week exceeded. Re-lash appointments exceeding 5 weeks will then be booked as a full set and charged accordingly.

Name *
Name
Date *
Date