*

Please Fill out the pre-procedure forms and attach a picture If there are no contraindications identified in your consent/release papers, I will provide you with a price based on a preliminary evaluation and skin analysis of your picture. Prices may be checked in the Services tab. The original pricing includes a touch-up, which must be conducted 4-6 weeks after the first procedure. We will send you a deposit invoice for 30% of the total service charge when we receive your online release form and application. Your deposit will be added to the total amount of your services on the day of your appointment. If you need to cancel or reschedule an appointment, please do so within 48 hours of the scheduled time, otherwise your deposit will be forfeit. If you do not get a response after 24 hours, please let us know at Emeraldisleaesthetics@gmail.com

Accept

Deny

Name *

First Name

Last Name

Birthdate *

Please enter your birthday

MM

DD

YYYY

Phone *

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Permanent makeup consent form *

For best results, clients will be required to return for at least one re-touch appointment. This will take place between 4-6 weeks after the initial procedure. Please note: if for any reason you cannot attend your touchup within the 4-6 week window (or as directed by your service provider additional charges may apply. • Please be aware that color intensity will be significantly darker and sharper immediately after the procedure. This will reduce by 30%-50% within 2 weeks of healing. • Although numbing cream is used during the procedure, slight sensitivity or discomfort may still be felt by sensitive clients. • Delicate or sensitive skin may be red and/ or swollen after the procedure. • Please wear your normal make-up (just on the area to be enhanced but nowhere else on the face) on the day of your procedure. • DO NOT drink alcohol the night before or day of your treatment. • DO NOT consume caffeine the day of your treatment. • DO NOT take any anti-infammatories for 24 hours before your treatment. • Any brow shaping will be performed by me the day of service. Please let brows grow out for 2 weeks before treatment. • Electrolysis treatments should be undergone no less than 5 days before the treatment. • AHA preparations should be undergone no less than 2 weeks before the treatment. • Chemical, laser peel, Retin-A, retinols/retinoids should not be utilized 2 weeks before or after the procedure **I have read and fully understood the above information provided and any risks involved with the use of topical anesthetic, and I therefore consent to the use of the anesthetic for the microblading procedure. **

Yes

No

General Consent & Procedure Permit Form *

• If an unforeseen condition arises in the course of the procedure, I authorize my therapist to use his/her professional judgement to decide what he/she feels is necessary under the given circumstances. I accept the responsibility for determining the shape and position of the procedure as agreed during consultation. • I understand that an allergy test does not guarantee that I will not develop an allergic reaction to the pigment. • I fully understand and accept that non-toxic, EU tested/approved pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years. Even once the color fades, pigment itself may stay in the skin indefinitely. • I have been informed that the highest standards of hygiene are practiced and that sterile, disposable needles and pigment containers are used for each individual, procedure, and visit. • I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results, and that 100% success cannot be guaranteed during the first procedure and/or touchup. I understand that I may have to return for a repeated procedure. • The result of the procedure is determined by the following: medications, skin characteristics (dry, oily, sun-damaged, thick or thin skin type), age, personal pH balance of your skin, tabacco use, alcohol intake and smoking, sun exposure, skin care regimen and post procedure after care. • Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 72 hours. • In some cases, bruising may occur. You may resume your normal activities following the procedure, however, using cosmetics, excessive perspiration, exposure to ANY moisture and exposure to the sun should be avoided completely during the first 2 weeks of healing and then limited until the skin has fully healed. Please see after care card for more details. You may resume wearing makeup on the area if necessary 2 weeks after the procedure, not before. • I have been advised that the true color will be seen 1 month after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition, among other things as previously described. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given. • To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being or final results as a direct or indirect result of my decision to have the procedure done at this time. • I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. • Being of sound mind and body, I herby release any and all responsibility. I accept any and all responsibility myself for any consequences that might stem om my decision to have any permanent cosmetics procedure performed by technician. • For the purpose of documentation record and use in portfolio, also consent to the taking of before and after photographs of my procedure **I have read and fully understood the above information provided and any risks involved with the use of topical anesthetic, and I therefore consent to the use of the anesthetic for the microblading procedure. **

Yes

No

Please read the following statements carefully: *

Microblading/shading is a way of cosmetic tattooing. A touch up procedure will be required at approximately 4-6 weeks. A minimum healing period of 4 weeks is required before a touch up procedure can be performed. On a rare occasion, the pigment may migrate under the skin. The procedure may be slightly uncomfortable. The pigments will fade to some degree. Immediately after the procedure, the pigment can appear 30-50% darker than the desired result. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be applied to pregnant women or nursing mothers. Permanent cosmetics cannot be applied to any person under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after microblading procedure, you should notify/ discuss with your doctor. Possible scaring may occur, but is extremely rare. **I have read and fully understood the above information provided and any risks involved with the use of topical anesthetic, and I therefore consent to the use of the anesthetic for the microblading procedure. **

Yes

No

Please provide your full name to agree *

First Name

Last Name

Have you recieved chemo therapy or radiation in the last 12 months? * *

Yes

No

Have you ever had an allergic reaction to any of the followng *

Lanolin

Latex Rubber

Vaseline

Metal

Hair Dyes

Paints

Crayons

Glycerine

Any Medications

Any Foods

NO

Have you ever had one of the following? *

Sensitivity to Cosmetics

Retin-A within last 2 weeks

Trichotilomania

Artificial Heart Valves

Haemophilia

High Blood Pressure

Circulatory Problems

Tumours

Growths or Cysts

Chemical or Laser Peel within 6 Weeks

AHA Preparations in the Last 2 Weeks

Hypertropic Scars

Healing Problems

Anaemia

Prolonged Bleeding

Low Blood Pressure

Diabetes

Do You Bruise or Bleed Easily

Fainting Spells or Dizziness

Liver Disease

Epilepsy

Thyroid Disturbances

Hair Loss

Cancer

Alopecia

Fat Injections

Botox Injuections

Collagen Injections

Keloid Scars

Do You Scar Easily

Are You Currently Pregnant or Nursing?

Thyroid disturbances

NO

Do you use Tobacco? *

Yes

No