Koko King Semi Permanent Makeup Consent Form
223 Dalhousie St, Ottawa, ON K1N 7E1
This form provides information about microblading/ Nano Brows which involves the application of semi-permanent makeup. You are encouraged to carefully review the information provided to make an informed decision as to whether to undergo the Semi Permanent Makeup procedure. This involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing. Initially the color will appear more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40-50%, soften, and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched up within 12-18 months. All instruments that enter the skin or encounter body fluids are disposable and disposed of after each use. Cross contamination guidelines are carefully adhered to. Generally, the results of Semi Permanent Makeup are excellent. However, a perfect result is not a realistic expectation, it is usual to expect a touch up after the healing is complete.
Possible risks, hazards, or complications:
PAIN: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.
INFECTION:Although rare, there is a risk of infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See "After Care" sheet for instructions on care.
UNEVEN PIGMENTATION: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance.
ASYMMETRY: Every effort will be made to avoid asymmetry but our faces are not symmetrical. Adjustments may be needed during the follow up session to correct unevenness.
EXCESSIVE SWELLING OR BRUISING: Some people bruise and swell more than others. Ice packs may help, and the bruising and swelling typically disappear within 1-5 days. Some people don’t bruise or swell at all.
ANESTHESIA: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform me now.
ALLERGIC REACTION: There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7-day patch test to determine this.
The alternative to these possibilities is to use cosmetics and not undergo this procedure.
CONSENT FOR SEMI PERMANENT MAKEUP :
Please read and initial if all following statements are true:
I am currently not under the influence of any drugs or alcohol.
I am NOT pregnant.
I do not currently take nor have taken Accutane within the last 12 MONTHS.
I have not had Botox and/or other cosmetic filler procedures within the past two weeks.
I have not had any surgery of any kind in the past 6 months.
I have not taken any blood thinning medication within the past 72 hours nor have i taken Aspirin within the past 24 hours.
Aftercare instructions have been explained to me and are attached to this consent form. A written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If i have questions I will contact my technician.
I will contact my physician if I notice any infection beginning to form.
I understand 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 the treated areas. They will alter the color.
I understand that the sun, tanning beds, pools, some skin care products and medications may affect my permanent makeup.
I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done today.
I understand that implanted pigment may changer or fade over time due to circumstances beyond the salon's control and I will need to maintain the color with future applications and a touch-up session in 4-8 weeks.
I acknowledge that the Semi Permanent Makeup procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedure such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
I have been quoted the cost of today's appointment which includes (1) touch-up within 4-8 weeks following today's appointment. After 12 weeks, a fee will apply for any further touch-ups. There will be no refund for this elective procedure.
I acknowledge that I am at least 18 years of age and 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. 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 materials given to me and I authorize Koreena King, to perform the Semi Permanent Makeup procedure on me. I hereby release Koreena King, and Smudge salon and its affiliates from any liability arising from the risks that are known and/or inherent in the Semi Permanent Makeup procedure.
- Must agree to move forward with treatment
Signature: August 20, 2019
Optional Photo Release Consent
Koko King would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc. Please circle "yes" or "no" below to indicate whether you consent to our use of your photographs for advertising purposes.
YES, feel free to use photos of me August 20, 2019