demo1 "" 1 Info 2 ConSENt 3 MEDICAL Client InfoAll fields are required. First and Last name Date of Birth Full Address Email Contact Number I am over the age of 18 Consent of ServiceCheck each box to confirm. I agree with the following: I have been informed of the nature,risk, and possible complications and consequences of skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and con-sequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fadding of pigmentation I understand that certain amount of discomfort is associated with this procedure and that swelling , redness and bruising may occur. I have been informed of the nature,risk, and possible complications and consequences of skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and con-sequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fadding of pigmentation There is a possibility of an allergic reaction to pigments. I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and touch up must be completed within 60 days of initial procedure. I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue. A patch test is advisable however it does not ensure a client will not have an allergic reaction. I release the technician from liability if I develop an allergic reaction to the pigment. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s). The microblading procedure, is a type of cosmetic tattooing, with the usual healing period of 4-6 weeks, after which the second visit is usually required, in some cases more visits maybe needed. During the healing period redness, swelling, scabbing of the skin, irritation, itching, minor bleeding rash and other effects are possible The final result will be achieved 6-8 weeks after the last visit. I am informed the pigments after initial procedure may partially and/or fully fade and/or disappear and full success cannot be guaranteed and the second touch up visit may be needed. I am aware that the results can be affected by: medication, skin type, smoking, drug and alcohol use, use of cosmetic skin care products and makeup on the eyebrow area, activities causing sweating, eyebrow plucking, cosmetic surgery, use of cosmetic injections and many other factors. I acknowledge that the final color and shade will be achieved after 6-8 weeks and the pigment colors and shade may vary with time. I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible. I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible. I acknowledge that complications as a result of semi-permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications. I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance. I understand that the taking of before and after photographs of the said procedure(s) are a condition of such procedure( s). Please click Yes or No with your signature if would like your photos to be used or not used for advertising. I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. Client Signature Client SignaturePut your signature herePlease sign above and then approveResetApprove Confidential Medical Profile Emergency contact number To avoid unforeseen complications, please click on each which that pertain to you. History of MRSA Botox Diabetes Hepatitis A B C D Forehead / Brow Lift Easy Bleeding Alcoholism Abnormal heart condition Taking vitamin E Pregnant / Breastfeeding Oily Skin Autoimmune disorder Chemotherapy / Radiation Tumors / Cysts growth HIV Any diseases or disorders not listed Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol Coumadin etc. Numbing difficulty with dental work Allergies to metals, food, etc. Do you use skin care products containing Retin A, Glycolic Acid, or Alpha Hydroxyl? Dateof appointment Client Signature Client SignaturePut your signature herePlease sign above and then approveResetApprove Submit > Prev Next