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Skye Microblading & Permanent Cosmetics

Let us do this part
Today's Date:
Mon May 6 2024 04:13
Practitioner:*
Please read and answer
CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETICS*
This form is designed to give information needed to make an informed
choice of whether or not to undergo a permanent cosmetics application.
If you have questions, please don’t hesitate to ask.
Although permanent cosmetic tattooing is affective in most cases, no
guarantee can be made that a specific client will benefit from the
procedure.
This is the process of inserting pigment into the dermal layer of the skin
and is a form of tattooing.
All instruments that enter the skin or come in contact with body fluids
are sealed a sterilized before use and disposed of after use. Cross
contamination guidelines are stickily adhered to.
Generally, the results are excellent. However, a perfect result is not a
realistic expectation. It is usual to expect a touch-up after the healing is
completed.
Initially the color will appear much more vibrant or darker compared to
the end result. Usually within 57 days the color will fade 10-50%, soften
and look more natural. The pigment is permanent but will fade
somewhat over time and will likely need to be touched-up through the
years.
PHOTOGRAPHY AND VIDEOGRAPHY RELEASE CONSENT*
Our insurance company requires “Before” and “After” photos/videos be
taken and kept on file. We would like your permission to use these
photos/videos for advertising. For example, in portfolios, online and in
print adds, etc. Your consent is necessary regarding this. Please circle
and indicate with your signature if you would like your photos/video
used or not used in advertising
POSSIBLE RISKS, HAZARDS OR COMPLICATIONS*
Pain: There can be pain even after the topical anesthetic has been used.
Anesthetics work better on some people than others.
 Infection: Infection is very unusual. The areas treated must be kept clean an
only freshly cleaned hands should touch the areas. See “After Care” sheet for
instructions on care.
 Uneven Pigmentation: This can result from poor healing, infection,
bleeding or many other causes. Your follow up appointment will likely
correct any uneven appearance.
 Asymmetry: Every effort will be made to avoid asymmetry but our 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 and swell more than
others. Ice packs may help and the bruising and swelling typically
disappears with 1-5 days. Some people don’t bruise or swell at all.
 Eye Exposure: There is small risk of eye injury when an eyeliner procedure
is performed. To avoid corneal abrasion, Celluvisc, a thick eye drop is used to
protect the eye prior to the procedure. Eye drops are used to cleanse and
flush the eye after the procedure is complete.
 Anesthesia: Topical anesthetics are used to numb the area to be tattooed.
Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or
gel form are typically used. If you are allergic to any of these please inform
me now.
 MRI: Because pigments used in permanent cosmetic procedures contain
inert oxides, a low level magnet may be required if you need to be scanned by
an MRI machine. You must inform your technician of any tattoos or
permanent cosmetics.
 Fever Blisters: If you are prone to cold sores or fever blisters, (herpes
simplex), there is a high probability that you will get them. It is advised that
you call your doctor for a prescription antiviral to help prevent this form
occurring.
 Allergic Reaction: There is a small possibility of an allergic reaction. You
may take a 5-7 days patch test to determine this.
Aftercare*
Aftercare instructions have been explained to me and a written
copy will be given to me to retain in my possession, which I will follow
to the best of my ability. If I have questions I will call or email you.
Discomfort*
I understand that a certain amount of discomfort is associated with
this procedure and that swelling, redness and bruising may occur.
Maintenance *
I understand that sun, tanning beds, pools, some skin care products
and medications can affect my permanent makeup.
Responsibility*
I will tell all skin care professionals or medical personnel about my
permanent makeup procedures, especially if I’m schedule for an MRI.
Responsibility & Communication*
I accept the responsibility to explain to you my desire for specific
colors shape, and position for any procedure done today.
Understanding*
I understand that implanted pigment color can slightly change or
fade over time due to circumstances beyond your control and I will need
to maintain the color with future applications and a touch up session
within 60 days.
Risks*
I acknowledge that the proposed procedure(s) involved risks
inherent in the procedure and have possibilities of complications during
and/or following the procedures such as: infections, misplaced
pigment, poor color retention and hyperpigmentation.
Cost*
I have been quoted the cost of today’s appointment, which includes
one (1), touch up after 30 days and within 60 days (this does not include material cost for touch-ups). After 60 days an additional fee
will apply and there will be no refunds for this elective procedure(s).
Consent*
I accept full responsibility for the decision to have this cosmetic
tattoo work done.
Approval*
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) and 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 to me and I authorize
Instructions*
AFTERCARE
After care is very important for producing a beautiful and lasting result.
 Keep the area clean by washing with freshly washed hands and a
mild soap. Do not use a washcloth or sponge to remove soap.
Simply splash with water. Do not use cleansing creams, acne
cleansers or astringents. Use a mild, natural soap.
 Apply the aftercare balm with freshly washed hands or a Q-tip. If
the balm is too stiff to use simply warm it up in a glass of warm
water or on your finger. Use the balm very sparingly. Too little is
better than too much. Blot off excess with a clean tissue. Never
touch the procedure area without washing your hands
immediately before.
 Do not scrub, rub or pick at the epithelial crust that forms. Allow
it to flake off by itself. If it is removed before it is ready the
pigment underneath it can be pulled out.
 Do not use any makeup near the procedure area including
mascara for eyeliner procedures for at least 3 days. Purchase new
mascara and makeup if possible to avoid contamination or
bacterial infection.
 Always use a sun block after the procedure area is healed to
protect from sun fading.
What’s Normal?
 Swelling, itching, scabbing, light bruising and dry tightness.
Ice packs are a nice relief for swelling and bruising. Aftercare
calm is nice for scabbing and tightness.
 Too dark and slightly uneven appearance. After 2-7 days the
darkness will fade and once swelling dissipates unevenness
usually disappears. If they are too dark or still a bit uneven after 4
weeks then we will make adjustments during the touch up
appointment.
 Color change or color loss. As the procedure area heals the
color will lighten and sometimes seem to disappear. This can all
be addressed during the touch up appointment and is why the
touch up necessary. The procedure area has to be completely
healed before we can address any concerns. This takes at least
four weeks.
 Needing a touch up months or years later. A touch up may be
needed 1 to 5 years after the initial procedure depending on your
skin, medications and sun exposure. We recommend a touch up
30 days after the first session (included in today’s price) and
every few years to keep them looking fresh and beautiful. Touch
up sessions after 60 days will be $195 or current touch up rate at
time of touch up.
Failure to follow after care instructions may result in infections,
pigment loss or discoloration.

I have read, understand and agree to the above instructions.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Legal Name:*
Chosen name:
Address:
Postcode:
Date of birth:*
You must be 18 or older
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.