CONSENT & RELEASE FORM Please complete the form below Name * First Name Last Name Phone * (###) ### #### Email * Emergency Contact Name: * First Name Last Name Emergency Contact Phone: * (###) ### #### Photo Release Form * Client photos are used for marketing or training material, advertisment, etc. Please check the box to authorize the use of any photos containing your image, print and/or online. I give consent to use my photos however the artist sees fit Medical History Do you have or previously had the following: (CHECK BOX IF YES) History of MRSA Botox (LIST DATE OF LAST TREATMENT BELOW) Diabetes Hepatitis A B C D Forehead/Brow Lift Easy Bleeding Facelift Abnormal Heart Condition Chemical Peel (LIST DATE OF LAST TREATMENT BELOW) Currently Pregnant or Breastfeeding Brow/Lash Tinting Autoimmune Disorder Oily Skin Cancer/Cysts/Tumors (LIST DATES BELOW) Accutane or Acne Treatment Chemotherapy/Radiation Tanning Bed Difficulty Numbing with Dental Work/Additional Med Prior to Dental Work Currently Taking Blood Thinners (ie: aspirin, ibuprofen, alcohol, coumadin, etc) Allergic Reaction to Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, other: Allergies to metals, food, etc: Do you use skin care products containing Retin-A, Glycolic Acid or Alpha Hydroxyl? Currently taking any medication? Any other disease or disorder applicaple to service I, the undersigned, agree that all of the above information is true and accurate. Expansion on any dates/medications/allergies/etc from above: * This form is designed to provide the information necessary to make an informed decision regarding microblading/micro-pigmentation eyebrow enhancement. * Microblading/Micro-Pigmentation is the process of inserting pigment into the basal layer of the epidermis - actually a semi-permanent form of tattoo All insturments that enter the skin or contact bodily fluids are disposable and immediately disposed of after use Cross-contamination guidelines are strictly adhered to Initially color appears vibrant and dark but fades 40%-50% (average) within 5-7 days for a softer, more natural look Advised to complete a touch-up procedure upon completion of healing process Further touch-up procedures are advised within 6 months to 2 years to maintain brow line as pigment is semi-permanent and fades over time Generally results are excellent, however, perfection is not a realistic expectation I have read and understand the points above Possible Risks, Hazards or Complications from Microblading * • PAIN – There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people that on others • INFECTION – Infection is very unusual. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See AFTERCARE INST for further instructions • UNEVEN PIGMENTATION – Can result from poor healing, infection, bleeding or other causes. Follow-up appointment will likely correct any uneven appearance • ASYMMETRY – Every effort will be made to avoid asymmetry, but human 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 than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some individuals do not 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/Liquid are commonly used. If you have an allergy or have had a reaction to any of these you MUST inform your eyebrow artist prior to the service • MRI – Because pigments used in permanent cosmetic procedures contain inert oxides, a low- level magnet may be required if you are scanned by a MRI machine. Your must inform you MRI Tech of any tattoos or permanent cosmetics. The alternative to these possibilities is to use traditional cosmetic and NOT undergo the Semi- Permanent Eyebrow Enhancement Procedure. I have read and understand the point above Statement of Consent & Recitals: * Please check each statement as agreement that you are giving consent to the service offered Aftercare insturctions have been explained and a written copy provided. I have been given follow-up instructions/contact information in case of questions/concerns. Retin-A, Renove, Alpha Gydroxy and Glycolic Acids (incl products containing these) must not be used on treated areas. Use of these will alter the color and/or premature exfoliation of the pigment. I understand that a certain amount of discomfort is associated with this procedure and swelling, redness and slight bruising may occur. Tanning beds, pools, some skin care products or medications may affect permanent makeup. Successful color saturation cannot be guaranteed in the presence of scar tissue. I understand the necessity of disclosing any permanent make-up procedures to medical personnel (especially for a MRI) or skin care professionals. I have been advised pigment/color can slightly change or fade over time. A touch-up is necessary for optimal results within 30 to 60 days. Follow-up appointments scheduled or completed after 60 days will be considered and priced as a new service. Some risks inherent to the procedure include infection, misplaced pigment, poor color retention and hyper-pigmentation. I authorzie Salon Kbeauty, Eyebrow Microblading Technician to complete semi-permanent eyebrow microstroking procedure today. 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 me. Deposit * Microblading is a Semi- Permanent Eyebrow Enhancement Procedure. Due to the time block and supplies, we are asking a $100 deposit to secure your appointment. I agree to the nonrefundable deposit Card Type: * Visa Mastercard Discover American Express Card Number: * Exp. Date: * MM DD YYYY Comments: Consent & Release * Please check this box as agreement to all statements above and as awareness of the procedure you have selected. YAS Thank you!