CLIENT CONSENT AND MEDICAL HISTORY FORM
This process of micro-blading involves inserting pigment into the dermal layer of the skin and is a form of tattooing. All instruments that enter the skin or come in contact with body fluids are sterile and disposable. All instruments are single use only and are disposed after each use. Cross contamination guidelines are adhered to always. Generally, results are positive but please take into consideration that a perfect result is not realistic. It is common to expect a touch-up after the healing is completed. Initially the color will appear much darker than the end result. Typically the color will fade 40-50% within 5-7 days, resulting in a softer and more natural appear. The pigment is semi-permanent and will fade over time thus needing to be touched-up within 6 months - 2 years. Possible risks, hazards or complications - Pain: There is a possibility of pain or discomfort even after the topical anesthetic has been used. - Infection: Although rare, there is a risk of Infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See “After Care” sheet for instructions 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 our faces are not symmetrical so adjustments may be needed during the follow up session to correct any unevenness. - Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help and the bruising and swelling typically disappears with 1-5 days. Some people don’t bruise or swell at all. - Anesthesia: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically 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 technician of any tattoos or permanent cosmetics. - Allergic Reaction: There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7 day patch test to determine this. Please initial to: Waive____ or Take______. The alternative to these possibilities is to use cosmetics and not undergo the Microblading procedure. While Microblading is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.
Consent and release for procedures performed: *
Consent and release for procedures performed:
Date *
Date
STATEMENT OF CONSENT AND RECITALS: Please read and initial all lines
All Boxes must be checked to proceed with appointment. *
Acknowledgement Release *
Acknowledgement Release
I certify that I have read or have had read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize THE FACE ROOM, to perform on my body the permanent cosmetic procedure desired today.
Date *
Date
Client Medical History Form
Birth Name *
Birth Name
Birth Date *
Birth Date
Phone Number *
Phone Number
Address *
Address
Emergency Contact
Emergency Contact Name *
Emergency Contact Name
Phone Number *
Phone Number
Do you presently have or previously had any of the following: *
I agree that all the above information is true and accurate to the best of my knowledge. *
I agree that all the above information is true and accurate to the best of my knowledge.
Date *
Date
Photography Release Consent (Optional)
You provide consent to appear in studio photography for client interactions with THE FACE ROOM.
You provide consent to appear in studio photography for client interactions with THE FACE ROOM.
The client shall consult a health care practitioner at the first sign of infection or an allergic reaction, and report any diagnosed infection, allergic reaction, or adverse reaction resulting from the tattoo to the artist and to the TDSH Services, Drugs and Medical Devices Group at 1-888-839-6676 *
The client shall consult a health care practitioner at the first sign of infection or an allergic reaction, and report any diagnosed infection, allergic reaction, or adverse reaction resulting from the tattoo to the artist and to the TDSH Services, Drugs and Medical Devices Group at 1-888-839-6676