Name *
Name
Phone *
Phone
I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated semi-permanent pigmentation procedure. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed, has been explained to me.
If an unforeseen condition arises in the course of the procedure, I authorize my therapist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances. I accept the responsibility for determining the color, shape and position of the microblading procedure as agreed during consultation. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years. Even once the color fades, pigment itself may stay in the skin indefinitely.
I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit.
I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeat procedure.
The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care.
Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed. Please see after care instructions for more details. The procedure results will look acceptable for you to appear in public without additional make-up on the brows.
I have been advised that the true color will be seen 6 weeks after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.
To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time.
I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure.
I can confirm that I have received a copy of after care details
I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, 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 is a tattoo process and therefore not an exact science but an art. I request the semi- permanent skin pigmentation procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences of the said procedure.
I understand that if I have any skin treatments, injectables, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent makeup procedure. I acknowledge some of these potential adverse changes may not be correctable.
I certify that I have read and initialed the above paragraphs and have had explained to my understanding the consent and procedure permit. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.
I give Jessica Gaisford at Age Later Aesthetics permission to perform my permanent makeup procedure
Name *
Name
Microblading can last 12-36 months depending on how my skin reacts to the procedure. There may be fading and/or discoloration. The result may not be what I expected to receive. I understand this is a semi-permanent makeup procedure that may take numerous follow-ups and touch ups to get a desired result.
There is no warranty or guarantee made to me as a result of this procedure and the final result cannot be guaranteed. There are no refunds for this procedure, as results will vary and individual results are not guaranteed.
I have seen and agree with the pre-drawn shape that my artist created. I understand that this is a guideline for the shape and size of my brow design and it may vary slightly once the procedure is done.
There may be risks and hazard related to performing this procedure. There may be discomfort and pain during this procedure. There is a possibility of bleeding, swelling, redness and allergic reactions to pigments.
Microblading is considered semi-permanent and can/will fade over time. Microblading, though semi-permanent, may last permanently and may not fade. Surgical procedures may be required to remove pigment from skin. These procedures may cause scarring and permanent damage to the skin.
Final results cannot be determined until brows are completely healed at 4 to 6 weeks. I understand that permanent and semi permanent makeup procedures cannot be guaranteed and results cannot be predicted, as there are many variables that contribute to the final result, such as aftercare, skin type, lifestyle, etc.
I have received post care instructions and will follow them to ensure results of my procedure are satisfactory.
I am NOT pregnant.
I am NOT under the influence of drugs and/or alcohol or any other mind altering substance.
I fully understand the procedure and give permission to my technician to perform the service of Microblading and all procedure and steps involved.
I have truthfully filled out the consent form and have informed my technician of all medications I have taken.
I release Jessica Gaisford and Age Later Aesthetics, LLC of all claims and injury, seen or unseen that may occur as a result of this procedure.
Signature *
Signature
Date *
Date