PERMANENT MAKEUP & MICROBLADING

You have the right to be informed so that you may make the decision whether or not to undergo the procedure(s) after knowing the risks and hazards involved. This disclosure is not meant to frighten you, it is simply an effort to make you better informed so you may give, or withhold, your consent to the procedure. Please read the statement below and write initials before each one, to indicate you understand them completely. As a client, it is your responsibility to inform the Technician of all possible concerns before they begin your procedure.

I am the person on the legal ID I have presented as proof that I am at least 18 years of age.

I am not under the influence of alcohol or drugs or any other substances, legal or otherwise and I am voluntarily submitting to receive body art without duress or coercion.

I understand that there is a chance I might feel lightheaded, dizzy and/or faint during or after the procedure.

I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.

I have been informed that I have to pay the touch up within 4 to 6 weeks after the procedure and if I fail to come back within that time frame I will have to pay for the whole procedure from beginning again. Further, I understand that Queen Ann Brow Permanent Makeup & Microblading has a 24 hours cancellation policy and I must cancel or change 24 hours prior to my appointment. If I fail to do so or if I no-show on my touch-up appointment day I will have to pay for my touch up appointment.

I understand that it is my responsibility to inform my technician of any problems that I (or my doctor) think could occur for any reason (including but not limited to: allergies, illnesses, medications-including aspirin and/or other medications that cause the blood to thin) and I understand that Queen Ann Brow Permanent Makeup & Microblading may elect to delay or not go forward with the procedure based on this information.

I understand that after my free 4 to 6 weeks touch up, that in order to maintain my procedure, I may have to come back for further touch ups for which I will have to pay for each touch up I receive.

I understand that tattoo inks, dyes, and pigments have not been approved by the federal Food and Drug Administration(FDA) and that the health consequences of using these products are unknown.

I understand there may be risks and hazards related to the performance of this procedure, including but not limited to: allergic reaction to the pigment and/or other products that will be used, light headedness, bleeding, bruising, swelling, scarring and infection.

I understand that TCA Peels or Laser Peels could cause more bleeding during the procedure.

No warranty or guarantee has been made to me as a result of this permanent makeup/camouflage/correction procedure, and although my technician will do their best to make sure I am happy with the result, the final result cannot be guaranteed. Tattooing is considered permanent, however, it will fade with time and therefore requires touch ups.

I understand some permanent makeup pigment can only be removed with a surgical procedure, and any effective removal may leave permanent scarring or disfigurement. Also, under rare circumstances, misplacement of the permanent makeup pigment can occur, requiring excision of the misplaced permanent makeup pigment. And also in rare cases, there may be permanent loss of eyelashes.

I understand that tattoo is permanent and that if I choose to have it removed, it may be expensive and leave scars.

I fully understand the questions, terms, and conditions of this Informed Consent, Medical History and Release Agreement, and all questions have been answered to my satisfaction and I have been given aftercare instructions for the procedure I am about to receive.

CONFIDENTIAL MEDICAL HISTORY

Have you had Botox/Dysport or any fillers in the last two weeks?

No Yes

Are you currently using, or have you used any products containing Retin-A or Hyaluronic Acid (or similar ingredient)?

No Yes

Do you use any medications that might affect the healing of the procedure you wish to receive? Please list all medications you are taking:

No Yes

Are you allergic to Latex?

No Yes

The information I have provided above is complete and true to the best of my knowledge.

Signature

I certify that this informed Consent Medical History and Release Agreement was completed by me and that all entries in it and information are true and complete to the best of my knowledge. I also certify that I have been fully informed of the risks of tattooing/permanent make up application, including but not limited to: infection, scarring, difficulties in detecting melanoma, and allergic reactions to permanent makeup/tattoo pigment, latex gloves, and other products used. Having been informed of the potential risks associated with getting the permanent makeup/tattoo, I still wish to proceed with application and I assume any and all risks that may arise from the procedure. I also certify that I take full responsibility and waive any claims against Queen Ann Brow and/or my Technician to the fullest extent permitted by law from all liability whatsoever, for any and all claims or cause of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application/implantation of permanent makeup pigment for eyeliner, eyebrows, lips, re-coloration, camouflage or otherwise, whether caused by the negligence or fault of either the Technician, Queen Ann Brow or otherwise.

Client’s Signature

FOR TECHNICAL USE ONLY:

Technician name (print name, sign and date):

Client has initialed / signed all areas of this document and I have answered all questions.

If single-use pre sterilized equipment is used, please provide Lot/ ID number

Queen Ann Brow Permanent Makeup & Microblading Informed Consent & Medical History Release Form

You must read and fill out this form completely, making certain that you understand everything and print your contact information clearly.

Queen Ann Brow Permanent Makeup & Microblading Informed Consent & Medical History Release Form

You must read and fill out this form completely, making certain that you understand everything and print your contact information clearly.

Esthetician Client Intake Form