Consent to Application of Semi-Permanent Makeup Procedure


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PEEK Microblading Pre Care Instructions 

Thank you for choosing ‘Peek Beauty’ for your Microblading experience.

Please make sure you read the following instructions to assure the best results for your procedure. 

 

It is very important to refrain from all alcohol, aspirin, or aspirin products, such as blood thinners.

Please refrain from Ibuprofen and Aleve for 48 hours prior to your appointment.

The only product for aches and pain that will not make you bleed, is Tylenol.

Also refrain from retinol products, Vitamin E, and fish oil capsules for 7 days prior to your application.

ALL of these make you bleed excessively. Excessive bleeding during the procedure will negatively affect the longevity of your semi-permanent makeup application. In some cases, the application will need to be prematurely stopped.

 

Please avoid energy drinks & coffee for up to 24 hours prior to your appointment. Not having caffeine in your system will help you to relax much more easily, as well as help to relax the facial muscles in the areas we will be working on. 

 

Thank you again and we look forward to seeing you. 

You’re one step away from having beautiful brows!!!

Consent to Application of Semi-Permanent Makeup Procedure

I,   am over the age of 18, I am not under the influence of drugs or alcohol. I am not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.

PROCEDURE:  MIRCOBLADING

NO. OF VISITS REQUIRED: 1-3

 

I have been informed of the nature, risks, and possible complications or consequences of semi-permanent pigmentation. I understand the semi-permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of procedure, including but not limited to the following: infections, scarring, inconsistent color, spreading, fanning or fading of pigments. There are no guarantees for microblading due to the complex nature of different skin types. No refunds are given.

 

Please click on each one to show that you have read.

 

 

 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 a form of tattooing and therefore not an exact science, but an art. I request the semi-permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of Mircoblading. 

  There is a possibility of an allergic reaction to the pigments. A patch test is advisable however, it does not ensure a client will not have an allergic reaction. I consent ________ (initial) or waive ____(initial) the patch test. If waived, I release the technician from all liabilities if I develop an allergic reaction to the pigment.

 I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable. 

  I have received both pre and post care procedural instructions and I will strictly adhere to such instructions. I understand that my failure to do so many jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly adhere to my doctor’s instructions before contemplating any semi-permanent cosmetic procedure around the lips. 

  I understand that taking before and after photographs of the said procedure are a condition of the procedure. I certify that I have read and initialed the above paragraphs and have had explained to me this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done.

 

Confidential  Medical Profile

To avoid unforeseen complications, please answer Y (yes) or N (no) to the following questions:

Do you have previous Permanent Make Up?

  If yes, when?  

Are you over the age of 18?

  Legal guardian’s initials  

Have you had Botox or injectables? 

 If yes when?  

Have you had Aspirin or any blood thinning medications/supplements within the last 7 days?

 

Do you take Antidepressants or mood altering medication?

 

Have you had chemical or laser peel? 

 If so when?  

Do you have any problems with healing?

 

Do you get fever blisters or cold sores?

 

Are you currently undergoing radiation or chemotherapy?

 

Are you currently using Retin-A or Alpha Hydroxyl skin care products?

 

Do you wear contact lenses?

 

Have you had caffeine products in the last 24 hours?

 

Are you taking any medication, including immunosuppressive, such as anti-inflammatory or steroids?

 

Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, or Caine family of drugs or Petroleum based products (Vaseline)?

 

Is there any history of skin diseases or remarkable skin sensitivities?

 

Are you pregnant or nursing?

 

Are you presently taking Vitamins A, E or fish oil in any form?

 

Are you required to take antibiotics during dental or invasive medical procedures?

 

Do you have any heart conditions?

 

Do you have Alopecia?

 

Are you currently on Accutane Treatment?

 

Do you have Keloid or Hypertrophy Scars?

 

Do you have Hepatitis?

 

Do you have Diabetes?

 

Any tendency to bleed excessively from minor cuts?

 

Do you have Epilepsy/ Seizures of any kind?

 

Do you have any Autoimmune Disorders?

 

Do you currently or have you had Cancer?

  If yes please explain   

Do you have HIV?

 

Please list any other medical conditions, and list all  

Doctor’s Name and Number  

 

Microblading  Cancellation Policy 

Please read our cancellation policy as a courtesy to ’Peek Beauty’ professionals, and in order to efficiently accommodate other clients.

 

The initial deposit of $200.00, is non-refundable.

 

If you need to reschedule your appointment, a 48 hours notice is required. Failure to notify our studio will result in a $100 rescheduling fee.

 

If a medical emergency arises, you must provide the proper medical documentation.

 

By signing this agreement, you acknowledge that you have read, understood and agree to all terms above.

 

Thank you and we look forward to assisting you.

 

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Signed by Sloane Padilla
Signed On: July 18, 2019

Peek Brow & Beauty Bar | Microblading | Makeup | Tatto Removal https://www.peekbrow.com
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Document name: Consent to Application of Semi-Permanent Makeup Procedure
Unique Document ID: b5a4bd1c034061e54c17fd512498ccfa74e090fc
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July 18, 2019 10:51 am MSTConsent to Application of Semi-Permanent Makeup Procedure Uploaded by Sloane Padilla - peekbrow@gmail.com IP 70.190.48.13