NAME DATE
DOB
ADDRESS CITY

STATE ZIP
HOME PH. WORK PH.

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

NO. OF VISITS REQUIRED: COST OF PROCEDURE(s):

I have been informed of the nature, risks, 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 understand the actual color of the pigment may be 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 microblading procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each indivudal’s reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent. X

I understand that if I have any skin treatments, 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 changes may not be correctable. X

I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. X

I understand that the taking of before and after photographs of the said procedure are a condition of such procedure. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and the procedure process. I accept full responsibility for the decision to have this cosmetic tattoo work done