Microblading – Consent Forms- Med Spa at Villagio

Please verify and sign below:

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

I have been informed of the nature, risk, 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, allergic reaction, scarring, inconsistent color, and spreading, fanning or fading of pigments.

I acknowledge that complications such as swelling, bruising, fever blisters, pigmentation migration or infection may occur, particularly in the event that pre-procedural and post-procedural instructions are not followed.

I understand the actual color of pigment may 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 permanent skin pigmentation procedure(s), and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure(s). I understand that if I have any skin treatment, 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 changed may be correctable.

It is not guaranteed ink will hold on: camouflaging, correcting, or oily skin. I have reviewed and received pre and post procedure instructions and will adhere to such instructions. I understand that my face may not be symmetrical; therefore, one eyebrow may be higher than the other in the procedure.

I agree to be numbed prior to the procedure and understand that in rare cases topical numbing agents might cause side effects. 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 follow my doctor’s instructions before contemplating any permanent cosmetic procedure around my lips.

I understand and authorize that before and after photos and/or videos might be taken and used in our records and/or marketing purposes.

By filling out the information and signing below, I certify I have read the above paragraphs and consent to the procedure. I accept full responsibility for the decision to have this cosmetic tattoo work done and understand that service(s) paid are not refundable. Client Name

Age

DOB

Zip code

ID type: Driver’s License / passport / other ID#:

Client Signature

Technician Signature

Date

No. of Visits Recommended:

*The 4-8 week Eyebrow and Eyeliner touch-up is $100 and is NOT included with other promotions. Any subsequent touch up is $250* *The 4-8 week Lip-Liner touch-up is $150 and is NOT included with other promotions. Any subsequent touch up is $250* We reserve the right to terminate any promotion at any time To be filled by Technician Procedure Performed

Body Location: Eyebrows / Eyes / Lips Technician Name

Colors Used