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WAIVER OF LIABILITY

Consent to Procedure  
I am over the age of 18 and desire Jakeline Freitas to perform the elective microblading procedure understanding that this procedure is for cosmetic purposes only and not for health reasons.  If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize her to do whatever necessary in the circumstances.  I am aware that no guarantee have been made to me concerning the results of the procedure(s).

I Agree

 


I also understand that the microblading procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used.  Laser treatments may also compromise the microblading procedure.  I fully understand as with all such procedures that this is not a science but rather an art and that anything that can go wrong may go wrong, such as, but not limited to the complications listed above.  I request the microblading procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s).

I Agree

 


Consent to Photographs and Videos:
For the purpose of documentation, I also consent to the taking of before, during and after photographs/videos of said procedure(s) which become the technician’s sole property and may or may not be used for what ever purpose deemed necessary including using pictures for social media and advertising publications.  IF YOU DO NOT WANT YOUR PICTURES POSTED ONLINE PLEASE ADVISE YOUR TECHNICIAN.  Understanding the microblading procedure, the procedure, the permanency of the procedure, the possible consquences of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize Jakeline Freitas to perform the microblading procedure(s).

I Agree

 

 

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Client's Date of Birth*
Client's 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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Procedure Fee I fully understand that the procedure costs $550.00, which is split into two payments of $450.00 being due on the first visit and $100.00 being due on the second visit. I understand that payment is due and earned at the time services are rendered.

Click to customize text

Click to customize question*
No
Yes
Consent to Procedure : I am over the age of 18 and desire Jakeline Freitas to perform the elective Microblading procedure understanding that this procedure is for cosmetic purposes only and not for health reasons. If any unforeseen conditions arise in the course of this procedure calling for his/her judgment for procedures in addition to, or, different from those now contemplated, I further request and authorize him/her to do whatever necessary in the circumstances. I am aware that no guarantee have been made to me concerning the results of the procedure(s)
Click to customize question*
No
Yes
I also understand that the microblading procedure carries with it the possible complications and consequences associated with this type of cosmetic procedure, which includes risk of infection, scarring, eye damage, inconsistent color, hemorrhage, and possible spreading, fanning or fading of pigments and or allergic reaction to any products used. Laser treatments may also compromise the microblading procedure. I fully understand as with all such procedures that this is not a science but rather an art and that anything that can go wrong may go wrong, such as, but not limited to the complications listed above. I request the microblading procedure, appreciating and accepting the permanency of the procedure as well as the possible complications and consequences of the said procedure(s)
Click to customize question*
No
Yes
Consent to Photographs and Videos For the purpose of documentation, I also consent to the taking of before, during and after photographs/videos of said procedure(s) which become the technician's sole property and may or may not be used for what ever purpose deemed necessary including using pictures for social media and advertising publications. IF YOU DO NOT WANT YOUR PICTURES POSTED ONLINE PLEASE ADVISE YOUR TECHNICIAN. Understanding the microblading procedure, the procedure, the permanency of the procedure, the possible consequences of the procedure, and that the procedure is for cosmetic purposes only, I hereby authorize Jakeline Freitas to perform the Microblading procedure(s).
Please select:*
No
Yes
Procedure Fee I fully understand that the procedure costs $550.00, which is split into two payments of $450.00 being due on the first visit and $100.00 being due on the second visit. I understand that payment is due and earned at the time services are rendered. Second Visit I fully understand that this procedure is a process and subsequent visits are necessary in order to achieve desired results. I understand that I must follow up within four to six weeks for my second visit in order to achieve maximum results and that I must pay a $100.00 fee at the time services are rendered. If I do not follow up within four to six weeks then any visit after six weeks then my fee will be $350.00 because the results of the first visit will have faded and more work will be required during the second visit to achieve maximum results. .
Click to customize question*
No
Yes
After Care Instructions: I will follow all "After Care" instructions explicitly. Failing to do so will compromise my final results. Warranties and Responsibilities: I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed.
Click to customize question*
No
Yes
Click to Check if you answer YES to any of these questions:
Are you allergic to penicillin or any other drug?*
No
Yes
New Option
Do you have any allergies to latex? Powder in gloves? Do you take Zovirax, Valtrex or Famvir? Do you have any kind of heart problem?
No
Yes
Are you allergic to or ever had any reaction to Polysporin, Bactracin, Neosporin, A&D, Vaseline or any other antibiotic, or topical healing ointments or products?
Please select:*
No
Yes
Are you allergic to Novacaine or any other caine anesthesia?
Please select:*
No
Yes
Have you had botox or any facial injection in the last 3 weeks? If you had botox in the last 3 weeks on your forehead or in between the eyebrows we will not be able to perform this procedure.
Please select:*
No
Yes
Do you have any skin condition such as eczema, rosacea and etc... ON YOUR FACE. (NOT YOUR BODY)
Please select:*
No
Yes
Are you presently taking any medications? List:
Please select:*
No
Yes

Please list your medications: *
Are you presently under a physicians care? What for?
Please select:*
No
Yes

please describe: *
Medical Consent and Procedure chart : If you are now taking or recently have taken any of these drugs please select below. You may need a physicians release prior to your procedure: Aspirin, Antibiotics, Accutane, Seizure medications, Medications for mood change, Anticoagulants, Diabetic medications, Heart medications, Tranquillizers, Steroid preparations, Blood thinners, Insulin injections Blood pressure medications, Pain or headache medications, Arthritis preparations, Hormones, Anti-anxiety medications, Medications for depression
Please select:*
No
Yes

Please describe:
Please select if you have or had recently any of the following. You may need a physicians release prior to your procedure. Anemia, Sinus infections, Blurred vision, Heart disease, Hypertension, Jaundice, Any breast problems, Collagen injections, Asthma, Chronic sinus congestion, Glaucoma, Heart condition, Diabetes, Hepatitis, Chronic skin problems, Gortex, Fever blisters, Seasonal hay fever, History of seizures, Heart murmur, Alopecia, Cancer surgery, Dermabrasion, Any other lip fillers, Herpes infections, Chronic/migraine headaches, Chronic eye conditions, Recurrent heart palpitations, Elevated blood pressure, Plastic surgery, Chemical peels, Nervous conditions
Please select*
No
Yes

Describe
Could you possibly be pregnant? WE CANNOT PERFORM PROCEDURES ON PREGNANT WOMEN.
Please select*
No
Yes
Are you a nursing mother? NO ANESTHESIA WILL BE APPLIED TO NURSING MOTHERS WITHOUT A DOCTORS NOTE ALLOWING US TO APPLY THE TOPICAL NUMBING.
Please select*
No
Yes
Do you have any allergies to any medications or latex?
Please select*
No
Yes
Do you have any allergies to Novacaine, Lidocain or any other topical anesthetics?
Please select:*
No
Yes

Describe:
I certify that I have read and initialed the above paragraphs and have had explained to me and fully understand the above consent and procedure permit; that the explanations therein referred to were made and I accept full responsibility for these and/or any other complications which may arise or result during or following the cosmetic procedure(s) which is to be performed at my request according to this consent were filled in before I signed this statement.
Click to customize question*
No
Yes
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.


Click to customize question*
No
Yes
Your Email please:

Email Address *
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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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