Scribd
Upload
73 views1 page

Consent To Application of Semi-Permanent Makeup Proced: Procedure: Mircoblading No. of Visits Required: 2

This document provides information and obtains consent for a microblading procedure. The client acknowledges being over 18, not under the influence, and understands the nature of the procedure and risks involved like infections, scarring, fading or spreading of pigments. The client also understands color may vary, patch testing is recommended but not guaranteed to prevent reactions, and post-care instructions must be followed. Photos may also be taken as part of the process.

Uploaded by

Mumy Mora
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
73 views1 page

Consent To Application of Semi-Permanent Makeup Proced: Procedure: Mircoblading No. of Visits Required: 2

This document provides information and obtains consent for a microblading procedure. The client acknowledges being over 18, not under the influence, and understands the nature of the procedure and risks involved like infections, scarring, fading or spreading of pigments. The client also understands color may vary, patch testing is recommended but not guaranteed to prevent reactions, and post-care instructions must be followed. Photos may also be taken as part of the process.

Uploaded by

Mumy Mora
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Consent to Application of Semi-Permanent Makeup Procedure

NAME: ____________________________ DATE: __________ DOB: ______________


ADDRESS: ___________________________ CITY: ___________ STATE: ____ ZIP: _______
HOME/CELL PHONE: _____________________ EMAIL: ___________________________

I, __________________ am over the age of 18, I am not under the influence of drugs or alcohol. I am not
pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of
cosmetic tattooing as well as the specific procedure to be performed has been explained to me.
PROCEDURE: MIRCOBLADING NO. OF VISITS REQUIRED: 2

I have been informed of the nature, risks, and possible complications or consequences of semi-permanent
pigmentation. I understand the semi-permanent skin pigmentation procedure carries with it known and
unknown complications and consequences associated with this type of procedure, including but not limited to
the following: infections, 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 a form of tattooing and therefore not an exact science, but an art. I request the semi-
permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the
possible complications and consequences of Mircoblading. _______(initial)

There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not
ensure a client will not have an allergic reaction. I consent ________ (initial) or waive ____(initial) the patch
test. If waived, I release the technician from all liabilities if I develop an allergic reaction to the pigment.
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. _______(initial)

I have received both pre and post care procedural instructions and I will strictly adhere to such instructions. I
understand that my failure to do so many jeopardize my chances for a successful procedure. If I am on any
medication for depression or any other mood altering prescription, I will advise my technician. If I have ever
had cold sores, I will consult with and strictly adhere to my doctor’s instructions before contemplating any
semi-permanent cosmetic procedure around the lips. ______ (initial)

I understand that taking before and after photographs of the said procedure are a condition of the procedure.
I certify that I have read and initialed the above paragraphs and have had explained to me this consent and
procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.

______________________________ _________________
CLIENT SIGNATURE DATE

You might also like