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Semi Permanent Tattoo

Client Consent / Information Form

 

       

Disclosure and Consent for lntradermal Cosmetic Procedures

I have requested information relating to the procedure of lntradermal Cosmetics so that I may make an informed decision as to whether or not to undergo the procedure.

The type of intradermal cosmetic procedure used will be Micro Pigment Implantation, the process of implanting micro pockets of pigment into the dermal layer of skin.

This is a form of tattooing used for permanent cosmetics and camouflaging skin imperfections such as scars and stretch marks.

I voluntarily request as my intradermal cosmetic technician, and such association technical assistance as he / she may deem necessary to perform on my body one or more of the following procedure(s),Eyebrow Microblading / Powdered brows / Lash enhancement  

 Please Initial:

I am in good health and not under the care of any physician.  


 

Please Initial:

I have been told that there may be known and unknown risks and hazards related to the performance of the planned procedure and I understand that no warranty or guarantees have been made as to the results.


I acknowledge the manufacturer of the pigment requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. 


I have been told that this procedure will involve pain and discomfort. 


I understand the markings are permanent and that there is the possibility of hyper pigmentation resulting from a procedure, especially in individuals prone to hyper pigmentation from scar or other injury.


I understand a follow-up / touch up procedure may be required / requested within 4-6 weeks after initial procedure at no extra cost. Any follow-up / touch requested / scheduled after 4-6 weeks of initial procedure will cost within 6 weeks to 2 months $ 75.00 / 2-4 months $ 100.00 / 4-6 months $ 150.00 / 6-8 months $ 175.00 / 8- 12 months 300.00 / 1 year and up $350.00 .. For all other procedures such as powdered brows and lash enhancement, prices vary based on the month. 


I understand other risks involved with the procedure may include, but are not limited to: infections, allergic and other reactions to applied pigments, allergic and other reactions to products applied during and after the procedure, fanning or spreading of pigments (pigment migration), fading of color.


I accept full responsibility for any and all, present and future, medical treatments and expenses I may incur in the event I need to seek treatments for any known or unknown reason associated with this procedure.


I have been given an opportunity to ask questions about the procedures to be used and the risks and hazards involved, and I believe that I have sufficient information to give informed consent.


I agree that should I have a complaint of any kind whatsoever, I shall immediately notify the The Threading Studio and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and The Threading Studio or the breach thereof, shall be settled by arbitration in the state of Texas in accordance with the Rules of the American Arbitration Association and judgment of the award rendered by the arbitrator(s) may be entered in any court that has jurisdiction. 


I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify the The Threading Studio, a health care provider and the Texas Department of State Health Services at 1-888-839-6676


I certify that I have read or had read to me and, this consent and fully explained and I understand its contents.


I have read or had read to me and received a copy of the Post Procedure Instructions vis a hard copy email and I understand its content.


Clients Signature:


Date: May 14, 2024

We want you to love your new look and will be available to answer any questions or concerns you have following your procedure. We are so pleased to have you as our client and we look forward to providing you wonderful services in the future.

Post Procedure Instructions

For all lntradermal Cosmetic Procedures:

  • Following treatment you may apply ice to the treated areas for 10-30 minutes. Ice helps to reduce the swelling and aids in the healing process.
  • After the procedure, apply anti-bacterial ointment / cream after the procedure for (First 2 days) and then use Vaseline (Vitamin A and E) for the next 5 days.
  •  Use sterile bandages(s) or other sterile dressing(s) when necessary.
  • 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 texas department of state health services, drugs and medical device group, at 1-888-839-6676
  • Do not rub or pick at the epithelial crust, allow it to flake off on its own. There should be absolutely no scrubbing, cleansing creams, or chemicals. Gently rinse the treated are with a mild anti-bacterial soap. Rinse with water and lightly pat the area dry. Do not expose treated areas to the full water pressure of a shower, until the area has healed.
  • Do not soak treated area in a bath, swimming pool or hot tub or steam areas. Do not swim in fresh, salt, or chlorinated pool water for 14 days following your procedure.
  • Limit sun exposure for 14 days following the procedure. To prevent fading of the pigment it is recommended to wear a sun screen with an SPF factor of at least 30 on any treated areas.
  • You will not be allowed to donate blood for 1 calendar year following your procedure, per the guidelines of the American Red Cross.
  •  I understand a follow-up / touch up procedure may be required / requested within 4-6 weeks after initial procedure at no extra cost. Any follow-up / touch requested / scheduled after 4-6 weeks of initial procedure will cost within 6 weeks - 2 months $ 75.00 / 2-4 months $ 100.00 / 4-6 months $ 150.00 / 6-8 months $ 175.00 / 8- 12 months 300.00 / 1 year and up $350.00.. For all other procedures such as powdered brows and lash enhancement, prices vary based on the month 

 Failure to follow post procedure instructions may result in loss of pigment, discoloration, or infection. Remember that the colors will appear brighter immediately following the procedure and will soften as the healing process occurs. A touch-up procedure may, or may not be necessary depending on the final result, which can be determined after healing is complete. If a touch-up is necessary, please call and schedule an appointment.

Remember that the colors will appear brighter immediately following the procedure and will soften as the healing process occurs. A touch-up procedure may, or may not be necessary depending on the final result, which can be determined after healing is complete. Please call and schedule for any touch up appointment at 214-500-0367 and if you have any questions or require further information please call on the given number.

I have read, or have had read to me, the above post procedure instructions and I fully understand the information contained therein.

Clients Signature:


Date: May 14, 2024

 

Pre-Treatment Advice and Procedures

Candidates who are not eligible

  • Nursing
  • Under Doctors treatment ( chronic)
  • Under chemotherapy

 Do's and Dont's

  • No fillers or Botox, chemical peels, and micro-needling- await time of 4 weeks is needed
  • doctors note is necessary if under treatment.
  • Since delicate skin or sensitive areas may swell slightly, or redden, it is advised not to make social plans for the same day. Lip liner may appear "crusty" for up to one week.
  • Please wear your normal make-up to the procedure. If you are having lips or brows done, please bring your favorite pencils.
  • If unwanted hair is normally removed in the area to be treated, i.e.; tweezing or waxing, the hair removal should be done at least 24 hours prior to your appointment. Electrolysis should not be done within 5 days of the procedure. Do not resume any method of hair removal for 1 week following your procedure.
  • If eyebrows are normally dyed, do not have that procedure done within 48 hours of your appointment. Wait 4 weeks following your procedure before dying eyebrows.
  • Allergy testing of the pigment is recommended before the planned procedure.
  • Limit the use of aspirin or ibuprofen prior to your scheduled procedure.

Please feel free to contact us with any questions regarding your appointment or the procedure itself. We are here to make you feel comfortable. We recommend using the space below to make notes on discussion items so that we may go over them together.


First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Driver License or ID information

Name as appears in DL *

Date of Birth : Please select in this order 1st year, 2nd Month and 3rd Day *

License / ID number : *

Expiration : *

Client Age : *

Issuing State : *
I hereby authorize photographs of the work performed to be taken both before and after treatment and that said photographs may be used for purposes of advertising and/ or training. Please select yes or no
Please select*
No
Yes
I hereby authorize photographs of the work performed to be taken both before and after to be maintained in my personal file only. Please select yes or no
Please select*
No
Yes
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

I am currently under the care of a physician and I am being treated for the following condition(s): *

Physicians Name :

Phone Number :

Address :

City :

ST & Zipcode :
I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment, however spot testing does not identify individuals who may have a delayed allergic reaction to pigment. I agree to:*

a spot test prior to application and I agree to release The Threading studio llc, assistants, and pigment manufacturer(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. 


Referred by :

Fees Discussed : *
Please select the procedure/s requested *
Microblading
Lash Enhancement
Powdered Brows
Lip Blushing

Technician Name : *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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