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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 on others.

Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. See “After Care” sheet for instruction 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 out faces our not symmetrical so adjustments may be needed during the follow-up session to correct any unevenness.

Excessive Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don’t bruise or swell at all.

Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are 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 MRI Technician of any   tattoos or permanent cosmetics.

The alternative to these possibilities is to use traditional cosmetic and NOT undergo
The Semi--‐Permanent Eyebrow procedure.

Consent and release for procedures performed:

April 15, 2024

Consent and Release Agreement

This form is designed to give information needed to make an informed choice of whether or not to undergo a 3D Eyebrow, Microblading, semi-permanent makeup application. If you have any questions, please don’t hesitate to ask.

Although 3D Eyebrow Microblading is effective 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 basal layer of the epidermis. It is a form of tattooing, though semi-permanent.

All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after use. Cross contamination guidelines are strictly adhered to.

Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is usual and advised to expect a Touch-Up after healing is completed.

Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time. 

Additional Touch-Ups are likely needed within 6 months to 2 years.

April 15, 2024

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Photography Release Consent

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.

Client Medical History Form

Do you have or previously had any of the following:

History or MRSA*
No
Yes
Botox*
No
Yes

Last treatment
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Forehead/Brow Lift*
No
Yes
Easy Bleeding*
No
Yes
Facelift*
No
Yes
Alcoholism*
No
Yes
Abnormal Heart Condition*
No
Yes
Take medication before dental work*
No
Yes
Chemical Peel*
No
Yes

Last treatment
Pregnant now - Breastfeeding now*
No
Yes
Brow Lash tinting*
No
Yes
Autoimmune disorder*
No
Yes
Oily Skin*
No
Yes
Cancer*
No
Yes

Year:
Accutane or acne treatment*
No
Yes
Chemotherapy/Radiation*
No
Yes
Tan by booth or salon*
No
Yes
Tumors/Growth/Cysts*
No
Yes
Difficulty numbing with dental work*
No
Yes
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc*
No
Yes
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lechithin, Propylene Glycol, Vitamin E Acetate, etc*
No
Yes
Any diseases or disorders not listed*
No
Yes
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxil?*
No
Yes

Please list any medications you are taking

I agree that all that above information is true and accurate to the best of my knowledge

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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