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Consent and Liability Release Form

CONSENT AND LIABILITY RELEASE
FOR MICROPIGMENTATION OF EYEBROWS

SECTION 1: ACKNOWLEDGMENTS AND AGREEMENTS
Please initial at the bottom of this section to acknowledge your agreement with the following statements:


That I have been given a copy of this Consent and Liability Release (the “Release”) prior to the Micropigmentation technique being performed on me.

That I have received a copy of the Micropigmentation Aftercare instructions. You will also receive aftercare instructions at your appointment.

That it is my responsibility to advise Monarch Brow and Facial Studio (Angela Hugghins) of any concerns I may have before participating in the                   Micropigmentation sessions.

That I have read and accepted the risks set forth in Section 2. I have been given the opportunity to ask questions, either by written or verbal                       communication, prior to signing this Release. As a result, I have sufficient information to give this informed consent.

That I must complete the Health Questionnaire in Section 3 before I can receive the Microblading technique from Monarch Brow and Facial Studio. I            understand my participation as a client may be refused depending on my responses, including but not limited to pregnancy, diabetes, and/or allergies.

That no warranty guarantee has been made to me as a result of this Micropigmentation technique, and that the final result cannot be guaranteed.

SECTION 2: RISKS

I acknowledge and accept the following risks:
During the treatment, despite all precautionary measures, infection is possible, though rare.


Despite application of the most advanced and top quality pigments, an allergic reaction is possible, though rare.


Any skin treatment applying semi-permanent or permanent make-up carries with it a possible adverse change that may not be correctable.


During and after treatment, temporary pain, infection, scarring, swelling, redness and/or itching may occur.


Depending on the skin structure, after the first treatment small scabs with a loss of drawn hairs or shading may occur and color intensity may change. Generally, eyebrows are up to 40% darker and 10-15% thicker in the first seven days. Color (i.e. color reflection) depends on the natural skin pigment. The shape of the eyebrows is determined according to my face proportions. I understand that symmetry is determined both manually and digitally, with closed eyes because of the negative impact of facial expression.


The pigment is absorbed differently due to differences in the skin quality, and therefore there may be inconsistent color, spreading, or fanning of pigments.
Depending on the skin structure, change in the color intensity is possible and one or more additional treatments will be required. The first correction is done six to eight weeks after the treatment. For oily skin it may be necessary to perform more corrections.


The minimum or maximum duration of eyebrow drawing cannot be determined with certainty.


Application of permanent makeup leads to skin injury and it is important to carefully and gently nurture the skin after the treatment to allow for healing without complications. Inadequate care in the healing phase of the skin can lead to poor results. I will therefore strictly adhere to the Micropigmentation Aftercare instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. Angela Hugghins and Monarch Brow & Facial Studio will not be liable for my failure to follow the Micropigmentation Aftercare instructions.


As part of the aftercare, I will not use any other creams on the eyebrow area except for the product given to me or Eucerin. Infection or allergic reaction may result with the use of other products.


I will avoid swimming, sunbathing, tanning salons, saunas, beauty treatments such as facials, training, or other sports accompanied by heavy sweating, and contact with dust for one week after the procedure. I will cleanse regularly and especially after sweating as the salt in sweat degrades the pigments during the week of healing.

SECTION 3: HEALTH QUESTIONNAIRE

To perform the Micropigmentation technique in a safe manner, you must disclose to your technician if you have any of the following issues. Angela Hugghins and Monarch Brow & Facial Studio will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether I can participate as a model.
I will tell my service provider if I have been diagnosed with any of the following diseases or use any of the following medications:
Hemophilia                    
Diabetes mellitus (diabetes)                  
Hepatitis A, B, C, D, E, F          
Skin diseases               
Eczema                   
Allergies                   
Autoimmune diseases           
Herpes zoster               
Current infectious disease/fever  
Epilepsy                
Cardiovascular problems       
Are you taking blood thinning medications (anticoagulants) or fish oil?
Are you pregnant?           
Do you have a pacemaker?       
Do you have a problem with healing of wounds?
Have you consumed drugs or alcohol in the last 24 hours?
Did you in the last 14 days undergo surgery, in which you were exposed to radiation, or any other medical interventions, such as chemotherapy?
                      

SECTION 4: GENERAL RELEASE AND WAIVER
I HAVE READ THIS WAIVER AND RELEASE AND UNDERSTAND THAT I AM SIGNING THIS WAIVER AND RELEASE VOLUNTARILY.
Sign name: 


Date: July 16, 2019

AFTERCARE INSTRUCTIONS


It is essential that you follow these instructions after your Micropigmentation sessions:
Day One (day of the treatment): AfterInked (ointment provided) product will be applied to your eyebrows before leaving the studio. Thirty minutes after your session (or as close to as possible) please rinse the eyebrows with water to remove the clear lymph, pat dry and let them be. Do not apply an extra ointment at this time. Wash your face in the evening as usual and use a gentle cleanser for eyebrows. Apply the provided ointment with a cotton swab in a thin layer to coat the fresh lines. It does not take much.


Day Two-Nine: Wash face as usual. Apply the AfterInked (or Eucerin if you run out of provided AfterInked ointment) to your eyebrows every two or three hours, except when sleeping. Apply with a cotton swab and use no aggressive movement or manipulation of the skin. Make sure your hands are completely clean before caring for your eyebrows.
The following MUST BE AVOIDED during all seven days post-Microblading procedure:
Eyebrow makeup
Increased sweating
Practicing or playing of sports
Swimming
Hot sauna or steam room
Sunbathing or salon tanning
Any laser or chemical peelings, and/or any creams containing glycolic acid or Retin-A on the face
Picking, peeling, or scratching of the micropigmented area in order to avoid scarring or removal of the pigment
Beach sand and saltwater (salt breaks down the fresh healing pigment)
Smoking
Drinking alcohol in excess as it may lead to slower healing of wounds
Touching the eyebrow area except for when rinsing/cleansing and applying of aftercare treatment with a clean cotton swab

Itching and flaking may appear during the first seven days post Micropigmentation procedure, however, experience has shown that these symptoms can be reduced by following the above instructions. Do not help the skin peel – let the peeling happen organically. 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.

WHAT TO EXPECT DURING AND AFTER MICROBLADING SESSIONS

Your new semi-permanent 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 first darken between days 2 and 4 and then soften gradually over the next few days, and the lines will become thinner. Do not be alarmed if you see some pigment in 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 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 protect your ink with a layer of sunscreen, SPF 30, or more. Sun exposure might cause the color to fade prematurely.
To preserve the look of your eyebrows, retouching every 18 months is necessary. Your eyebrows will fade gradually over time, which is desired as our faces and coloring change.
You can now enjoy your beautiful new semi-permanent eyebrows!

 

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*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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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