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CONSENT AND RELEASE AGREEMENT

Please expand all the Section Tabs below by clicking on the Section Titles, read the content one by one, fill up the Consent and Release Agreement Form and check the Acknowledgement at bottom of the form.
Page 1: 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.
Page 2: Statement of Consent and Recitals
Pain
There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others.

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 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.

Page 3: Possible Risks, Hazards or Complications
  • I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.
  • I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.
  • I understand that tanning beds, pools, some skin care products and medications can affect my permanent makeup.
  • I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue.
  • I will tell all skin care professionals or medical personnel about my permanent makeup procedure, especially if I am scheduled for an MRI.
  • I accept the responsibility to explain to you my desire for specific colors, shape, and position for any procedure done today.
  • I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the color with future applications and a touch-up session within 60 days.
  • I acknowledge that the proposed procedures(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyperpigmentation.
  • I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Touch-ups must be completed within 60 days of initial procedure.
  • I have been quoted the cost of today's appointment, and the cost of the touch-up. Touch-ups must be completed within 60 days of initial procedure to be considered a touch-up price. 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). 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 NIK J as my Eyebrow Microblading technician to perform on my body the 3D Eyebrow Microblading procedure desired today.
Page 4: Photography Release
We would like your permission to use your photos on our media pages. For example, our online portfolio, Faceboook and Instagram pages etc. Please remember, your decision to come to High Brow Society most likely came after viewing some of these photos! Please pay it forward :) Your consent is necessary regarding this. Please indicate with yes or no if you would like your photos used or not used in advertising at the bottom of this form.

Page 5: Microblading Aftercare Instructions
Day One: (Day of Treatment)
Keep the brows covered with medical silicone sealant.

Day Two and Forward
After 24 hours, gently wash off the medical silicone with lukewarm water. Be careful not to tug or scrub the brows. Apply post-care ointment (Aquaphor or grapeseed oil) on your eyebrows 1-3 times a day. Apply the post-care ointment with a cotton swab, and use no aggressive movement and/or manipulation of the skin. Make sure your hands are completely clean before caring for your eyebrows.

The following must be avoided post-microblading procedure:
  • Application of any brow makeup for 2 weeks.
  • Scratching or removal of scabs, dry skin/flakiness.
  • Direct water on the brow tattoo and the use of cleansers, soaps and heavy creams. Wash around the areas using a cleaning cloth or oil-free makeup wipe.
  • Activities that will cause sweating for 10 days.
  • Swimming pools, hot tubs or other bodies of water for 14 days.
  • UV exposure (including tanning booths).
  • Laser- light therapy, as it can darken/lighten or distort the pigment.
  • Exfoliants, retinol acids or AHA's on the area for 30 days after the appointment (causes premature fading).
  • Massages, facials or skin treatments.
  • Touching of the eyebrow area except for when rinsing and applying the post-care ointment with a cotton swab
Before showering apply a layer of post-care ointment to protect your eyebrows from moisture. During the shower keep vour face away from the shower head. Itching and flaking may appear during the first seven days post-microblading procedure. However, experience has shown that by following these after-care instructions, these symptoms may quickly disappear. The healing of deeper wounds might last between 14-21 days. Touch-ups and/or correction of the shape-design is recommended only after this period. If you have any unexpected problems with the healing of the skin such as excessive swelling, redness, drainage or discomfort, please follow up with a medical provider.
Aftercare image
Page 6: What to Expect During & After Your Microblading Session
  • Your new temporary eyebrows will go through several phases during the healing cycle.
  • The pigment will appear very sharp and dark immediately after the procedure. This is because the pigment is still sitting on top of your skin, and has not yet settled in completely. The color of the pigment will soften gradually.
  • Do not be alarmed if you see some pigment on the cotton swab, as this is excess pigment and/or body fluid that is naturally exiting your skin.
  • Once the healing of the skin starts taking place, it will look like dandruff flakes or dry skin. This might give you the impression that the color pigment is fading too quickly, however, this is just superficial color and dry skin being naturally removed from your eyebrows.
  • Once completely healed, always apply a layer of sunscreen SPE 30 up to SPF 50 on your eyebrows when exposed to the sun. Sun exposure might cause the color pigment to fade away more quickly. You can now enjoy your beautiful new brows.
  • You will simply love your new gorgeous fresh look!
Page 7: Consent & Release Agreement Form
First Name:
Last Name:
Date:
BirthDate:
Address:
Phone:
Email:
Emergency Contact Person:
Phone:
Do you have or previously had any of the following: (Select Yes or No)
History of MRSA:
Yes No
Diabetes:
Yes No
Hepatitis A B C D:
Yes No
(Type: )
Easy Bleeding/Hemophilia:
Yes No
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc:
Yes No
Pregnant or Breastfeeding now:
Yes No
Cancer:
Yes No
(Year: )
Chemotherapy/ Radiation:
Yes No
Tumors/ Growth/ Cysts:
Yes No
Difficulty numbing with dental work:
Yes No
Skin diseases:
Yes No
Eczema:
Yes No
Are you prone to herpes?:
Yes No
Infectious diseases now/high fever now:
Yes No
Epilepsy:
Yes No
Oily Skin:
Yes No
Accutane or acne treatment:
Yes No
(Completed when? )
Botox:
Yes No
(Last treatment: )
Forehead/Brow Lift/Facelift:
Yes No
(Date of procedure: )
Chemical Peel:
Yes No
(Last treatment: )
Brow Lash Tinting:
Yes No
(Last treatment: )
Tan by booth or salon:
Yes No
Do you have problems with healing of wounds? :
Yes No
Have you consumed drugs or alcohol in the last 24 hours? :
Yes No
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc:
Yes No
(List: )
Allergies to metals, food, etc:
Yes No
(List: )
Any diseases or disorders not listed:
Yes No
(List: )
Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxy?:
Yes No
Please list any/all medications you are taking:
I would like my photos to be used in advertising.
Yes No
 I have expanded and read all 7 pages above. By entering today's date, it is written warranty that all statements made by you on this application are true and correct to the best of your knowledge.
Signature (Initial)
Date
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