Full Name: Email:Phone Number:
Are you pregnant?
Have you consumed any alcohol or blood thinners within the last 24 hours? ?
Do you have any allergies to lidocain, tetracaine, benzocaine or white petroleum?
Have you had any Chemical peels within the last 3 months?
Have you ever had any permanent cosmetics or tattoos applied?
Do you routinely use Retin-A, glycolic or other ex-foliating areas around your eyebrows?
Are you allergic or sensitive to any metals? Do you have any difficulty healing from small wounds?
Do you have oily skin?
Do you get Botox injections? Are you undergoing radiation or chemotherapy?
Do you tan in direct sunlight or a tanning bed on a regular basis?
Have you consumed any caffeine today?
Do you hyperpigment or hypoppigment?
Do you get keloids?
Do you scar easily from minor skin injuries?
Do you bleed excessively from minor cuts?
Do you have any type of diseases / disorders that are transmitted through blood contact?
If you answered “YES” to any of these questions listed above, please use the blank portion of this form to provide a brief explanation and correlate our answers to the specific question number. A “YES” does not necessarily indicate that you are not an acceptable candidate for permanent cosmetics. It may simply be information that is valuable to me as your technician. Each person’s body is unique and certain health conditions that affect healing may require you to consult with your physician before proceeding. If this form has bot addressed a medical condition you have, please list it and inform your technician.
I acknowledge by signing this agreement that I have been given full opportunity to ask any questions I may have and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advise of the facts set forth below and I agree as follows:
I release all rights to any photographs and videos taken and give my complete advance consent for their reproduction in any form
I have thoroughly read the Frequently Asked Questions section of Smart Set ensure I am a candidate for this procedure and have also read the pricing page in full
I do not have a history of or currently have Diabetes, Epilepsy Hepatitis, H.I.V., A.I.D.S, tuberculosis, or any other communicable disease. I also do not have an allergy to antibiotics, a heart condition, Rosacea, and am not currently receiving Chemotherapy.
I do not have a history of or currently take medicine that may thin my blood
I am not under the influence of drugs or alcohol
I don’t have a medical or skin condition, such as, but not limited to Acne, Scarring, Eczema, Psoriasis, Freckles, Moles, or Sunburn, in the area to be Microbladed.
I am not currently pregnant or breastfeeding
I acknowledge that this procedure is a permanent change to my appearance.
To my knowledge I do not have any physical, mental, or medical impairment which might affect my decision to have the technician provide this procedure.
I acknowledge that I have truthfully represented myself to be 18 years of age or older, with a valid driver’s license as identification.
I understand that Microblading / Micro Pigment Implantation is the process of implanting micro insertions of pigment into the dermal layer of the skin. Micro pigment implantation is a form of tattooing used for the purpose of semi permanent cosmetic tattooing.
I understand that there may be unknown risks and hazards related to the performance of the procedure and I understand that there is no warranty or guarantees that have been made to be about the result.
Due to the fact that my approval is obtained prior to my permanent cosmetic design/shape and color choice, I understand that no refunds are to be given.
I understand that there are a number of variables that affect the healing process and pigment retention, and that every client’s results are different. These variables have been explained to me.
I understand the possible risks involved in this procedure such as bit not limited to: infection, allergic reaction to pigment.
I have been given the opportunity to ask any questions that I may have about any of these issues
I understand that allergic reactions are extremely rare however they can occur. If they do occur, they may be difficult to treat.</p>
I acknowledge the manufacturer of the pigment suggest a spot test and specificallydisclaims any responsibility for any adverse reaction to applied pigments.
I understand that spot testing may identify individuals who develop an immediate allergic reaction to pigment.However, spot testing may not identify individuals who may have delayed allergic reactions.
I agree to receive OR waive a spot test from my permanent cosmetic technician prior to applicationand I agree to release the technician and pigment manufacturer from any and all liability related toallergic reactions.
I understand that while there will be analgesic / topical anesthetic used that the procedure may causepain and discomfort.I agree to sit through the entire procedure despite this.
I understand that this is to be considered a permanent procedure and there is a chance of hyperpigmentation, especially in individuals that are prone to hyper pigmentation and scarring.
I agree to book a 6-8 week follow up appointment. I understand that some clients may requireadditional work to achieve their final desired look and that this can be done at an additional cost
I agree to accept full responsibility for any and all, present and future, medical treatments andexpenses may incur in the event I need to seek treatment for any known or unknown reasonassociates with this procedure.
In the event of CAT Scan or MRI, I understand that tattoos may cause a warming, burning and/ortingling sensation in the permanent cosmetic procedure area due to Iron Oxide( metallic salts ) properties of some pigments. I should advise my physician that I have permanentcosmetics ( a tattoo ) in the event of an RI or CAT Scan.
The fee for permanent cosmetic procedures has been explained to me and has been agreed upon. Iunderstand the total fee for services rendered is due upon completion of the initial procedures andthat there will be separate fees for any future modification of the design(s) or major color change(s).
I certify that this form has been fully explained to me and that I have read it and fullyunderstand its contents.
A 72 hour cancellation notice is required to cancel an appointment. If you fail to cancel your appointment within the 72 hours, FULL PAYMENT WILL BE REQUIRED TO RESCHEDULE. No exceptions. An additional $50 deposit will be required to make a new appointment reservation.
Rescheduling/Late Policy: To avoid unfair delays to clients, if you are more than 15 minutes late to your appointment it will be necessary to reschedule.
We understand that unforeseen circumstances may arise that could force you to postpone/reschedule your procedure. Please understand that such changes affect not only your technician, but other clients as well. If you choose to reschedule your appointment, a minimum 48 hour advance notice is mandatory or the deposit becomes non-refundable. If you DO NOT reschedule you will lose your deposit and any other future appointments will require another $50 deposit to secure your appointment.
No Show Policy:
Any client that does NOT show for a scheduled appointment, will forfeit their deposit and will be required to pay for any future appointments in full plus the fee for the missed appointment/s before being rescheduled. NO EXCEPTIONS.
I have received aftercare instructions. I have asked any questions I may have and I fully understandthe instructions.
Leave this empty:
Signed by Sonya Godwin
Signed On: December 10, 2018
If you have questions about the contents of this document, you can email the document owner.
Document Name: Microblading form
Agree & Sign