Barrhaven Microblading Consent form

[Barrhaven] Microblading consent form

Microblading Consent - Personal Information section

Name(Required)

First Last

Phone(Required)

Date of Birth (for Birthday promotion)

Email(Required)

Address

Street Address Province Postal Code

Consent section

I understand that microblading is a form of permanent makeup (a cosmetic tattoo). It will result in a permanent change to my appearance, and no representations have been made to me as to the ability to later change or remove the result.(Required)

I agree

I understand that there may be some discomfort or pain during the procedure, and that other side effects may include minor and temporary bleeding, bruising, redness, other discoloration and swelling. Fading or loss of pigment may occur. Secondary infection in the treated area may occur; however, if properly cared for, this is rare.(Required)

I agree

I understand that it is not possible to determine in advance whether I might have an allergic reaction to the pigments or products used, and I accept that risk. I have informed my technician of any existing problems.(Required)

I agree

I understand that my body is unique and my technician cannot predict how my skin will react. No guarantees have been made to me concerning the results, and the professional recommendation is a NATURAL LOOK.(Required)

I agree

I understand that microblading is not a one-step process and requires subsequent visits to achieve the desired result. The fee includes my first visit and ONE perfecting visit. Maintenance touch-ups are scheduled as needed and may vary from six months to three years. Fees for maintenance visits, pigment replacements, and scar camouflage are based on an hourly fee.(Required)

I agree

I understand that with time, pigment can and will fade and change color according to metabolism, skin type, age, and exposure to sun, smoking, alcohol, medications, Retin-A and glycolic acids. Future laser treatments or other skin-altering procedures may also alter my microblading, and this is not the fault of my technician.(Required)

I agree

I accept responsibility for approving the color, shape and position of my brows before the procedure. I understand the healed color may be modified slightly by the tone and color of my skin.(Required)

I agree

I understand that before and after photographs of the procedure are required.(Required)

I agree

I understand that if I have a CAT scan or MRI, I must inform my physician that I have iron oxide permanent cosmetics, as some pulling or burning sensation may occur.(Required)

I agree

I have received the pre- and post-procedure care instructions below and agree to follow them.(Required)

BEFORE YOUR APPOINTMENT
- Any tweezing or waxing should be done at least 48 hours before the procedure; electrolysis no less than five days before.
- Any eyebrow tinting should be done no sooner than 48 hours before the procedure.
- Brows can look darker and bolder than the final result while healing. Some clients prefer not to make social plans for a day or two after.

AFTER YOUR APPOINTMENT
1. Do not use any Retin-A or Glycolic Acids while healing.
2. Do not use Peroxide or Neosporin on the area.
3. Do not scrub or pick the treated area.
4. Do not expose the area to sun or tanning beds.
5. Avoid facials, swimming and/or whirlpools for at least five days.
6. Do not dye or tweeze eyebrows for one week, and do not resume any hair removal on the area for two weeks.
It is normal to lose about 1/3 of the color while healing. A touch-up visit is needed 4 to 8 weeks later before the work is complete.
FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN LOSS OR DISCOLORATION OF PIGMENT.

I agree

No coffee or alcohol before your appointment(Required)

No coffee or alcohol 24 to 48 hours before the appointment.

I confirm I have had no coffee or alcohol 24 to 48 hours before my appointment.

I understand that my technician does not practice medicine. I confirm the information I have given is accurate, and I will tell my technician about any changes. This agreement remains in effect for this procedure and all touch-ups and follow-ups with my technician.(Required)

I agree

Signature(Required)

By signing below, I verify that I have read and understand the above statements and agree to them.

Signature Date(Required)

Medical information section

Pregnant or nursing(Required)

YES

Aspirin or blood thinning products within the last 7 days(Required)

YES

Alcohol, caffeine, cannabis or mood altering drugs today(Required)

YES

Diabetes(Required)

YES

Heart condition, pacemaker, stroke, chest pain or shortness of breath(Required)

YES

Epilepsy or seizures of any kind(Required)

YES

Autoimmune disorder, Hepatitis, Jaundice or HIV(Required)

YES

Currently undergoing radiation or chemotherapy, or any cancer(Required)

YES

Accutane treatment within the last year(Required)

YES

Botox within the last 2 months(Required)

YES

Using Retin-A, Alpha Hydroxy or glycolic acid skin care products(Required)

YES

Taking immunosuppressive medication, anti-inflammatories or steroids(Required)

YES

Taking Vitamin A and/or E supplements(Required)

YES

Problems with healing, or a tendency to bleed excessively from minor injuries(Required)

YES

Keloid or hypertrophic scarring(Required)

YES

Skin disease or skin irritation near the brows (psoriasis, eczema, rash, sunburn, acne)(Required)

YES

Hyper-pigmentation (darkening) or hypo-pigmentation (lightening) of the skin(Required)

YES

Allergies to latex, metals, makeup, topical antibiotics or numbing creams (e.g. Polysporin, Neosporin, "Caine" family, petroleum)(Required)

YES

Previous problems with tattoos, or advised by a physician not to have a tattoo at this time(Required)

YES

Previous permanent makeup or microblading on the brows(Required)

YES

Trichotillomania or alopecia(Required)

YES

Required to take antibiotics before dental or invasive medical procedures(Required)

YES

Currently sick (cold, flu, etc.)(Required)

YES

If you answered YES to any question, please explain and list all medications you are taking

Client Signature(Required)

The Information I have given on this form is correct. I have not misrepresented myself nor have I withheld any medical information, surgical state or condition.

Signature Date(Required)

May we( Beauty Time Centre inc) take your photo?(Required)

YES

Photo and Video Consent section

PHOTO/VIDEO CONSENT(Required)

I, the undersigned, give my irrevocable permission to Beauty Time Centre Inc., (BTCI), and/or
parties designated by BTCI, to photograph/video me and use such photograph(s)/video(s) in any
form of media, for any and all promotional/marketing purposes including advertising, display,
audiovisual or exhibition.
I acknowledge that these images may be used on various platforms owned, controlled by, or
associated with BTCI, including social media, the internet, print and any other suitable medium.
I further consent to the use of my name in connection with the photograph(s)/video(s) if needed
by BTCI and/or parties designated by BTCI.
I understand and agree that I will not receive any payment or compensation for my time or
expenses or any royalty for the publication of the photograph(s)/video(s) or the use of my name
and I hereby release BTCI and/or any parties designated by BTCI from any such claims.
My consent and release shall be binding on me and my estate.
I certify that I have read and fully understand this consent and release, and that all questions
pertaining to this consent have been answered to my satisfaction.

I agree to the photo and/or video policy.

Name(Required)

First Last

Date(Required)

Signature(Required)

Parent or Guardian (if Client is under 18 years of age) Name & signature

Parent or Guardian Name

First Last

Signature Date

Parent or guardian Signature

Recptionist/Technician section

Receptionist/Technician Name

First Last

Signature date

Receptionist/Technician Signature