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Bare Studios Microblading Waiver


Bare Studios Microblading Consent Form

 

This form is designed to inform you and help guide you through the process of semi-permanent makeup safely. 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.

 

 

Possible risks, hazards, or complications:

 

PAIN: I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur. There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others. 

 

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.

ALLERGIC REACTION: There is a possibility of an allergic reaction of the pigments or other materials used. You may take a 5-7 day patch test to determine this. 

 

EXCESSIVE SWELLING or BRUISING: I understand that some swelling and bruising may occur. 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. 

ASYMMETRY: Every effort will be made to avoid asymmetry but our faces are not symetrical. Adjustments may be needed during the follow up session to correct any minor imperfections.

Please initial to waive patch test


 

CONSENT FOR MICROBALDING PROCEDURE:

Please read and sign if all the following statements are true and you agree to proceed

I am currently not under the influence of any drugs or alcohol.

I am not pregnant.

I do not currently take nor have I taken Accutane within the last 12 months.

I have not had botox and/or other cosmetic filler procedures within the past 2 weeks.

I have not had any surgery of any kind in the past 6 months. If so, I would fully disclose it.

I have not take any blood thinning medication within the last 72 hours nor have I take aspirin within the past 24 hours.

Aftercare instructions have been explained to me. A written copy will be given to me to retain in my possesion. If I have any questions I will contact my technician.

I will contact my physician if I notice any infection beginning to form.

I understand some discomfort is asssociated with this procedure which may inlcude swelling, redness, and bruising.

I understand that Retin A, Renova, Alpha Hydroxy, and Glycolicy acid must not be used on the treated area. They will alter the color.

I understand that the sun, tanning beds, pools, and some skin care products or 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 change or fade over time due to circumstance beyond the technician'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 mircoblading porcedure invloves inherent risk and that there is a possibility of one or more complications and/or following the procedure which may include: infection, misplaced pigment, poor color retention, and hyper-pigmentation.

I have been quoted the cost of today's appointment, and cost of a touch-up appointment 6-8 weeks following todays appointment. 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 and fully comprehend all the contents of this form.

I understand the risks and alrernatives involved in this procedure and I have had the opportunity to ask questions about the procedure.

I have reviewed and approved all the contents provided to me and I authorize SG Artistry to perform the microblading procedure on me.

I hereby fully authorize SG Artistry to move forward with the procedure and no liability will be assumed by SG Artistry in the event of any complications before, during, or after the procedure.

I Agree
 

-Must check this box in order to proceed

 

Please sign below




First Clients Name
First Name*
Last Name*
Phone*
First Clients Date of Birth*
Date of Birth
First Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
First Clients Signature*
Second Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Second Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Third Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Third Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Fourth Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Fourth Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Fifth Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Fifth Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Sixth Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Sixth Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Seventh Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Seventh Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Eighth Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Eighth Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Ninth Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Ninth Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Tenth Clients Name
First Name*
Last Name*
Clients Date of Birth*
Date of Birth
Tenth Clients Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
Clients 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
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Artist signature: Silvana Gavoci
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 Date of Birth*
Date of Birth
Parent or Guardian's Information
History of MRSA*
No
Yes
Easy Bleeding/Hemophelia*
No
Yes
Diabetes*
No
Yes
Hepatitis A B C D*
No
Yes
Pregnant or currently breastfeeding*
No
Yes
Cancer*
No
Yes
Abnormal heart condition*
No
Yes
Cancer treatments including chemotherapy or radiation*
No
Yes
Signs or diagnosis of tumor, growths, or cysts*
No
Yes
Difficulty with numbing/anesthetics*
No
Yes
Autoimmune disorder*
No
Yes
Blood thinners including but not limited to aspirin, ibuprofen, alcohol, coumadin*
No
Yes
Skin disease or irritation*
No
Yes
Eczema*
No
Yes
Infectious diseases or fever*
No
Yes
Epilepsy*
No
Yes
Pacemaker*
No
Yes
Oily skin*
No
Yes
Accutane or acne treatment*
No
Yes
Botox/forehead/browlift/facelift*
No
Yes
Tan by booth, sun, or spray tan*
No
Yes
Chemical peel or any facial treatment*
No
Yes
Have you consumed drugs or alcohol in the last 48 hours*
No
Yes
Any ALLERGIES which may include lidocaine, tetracaine, epinephrine, dermacaine, benzyl alcohol, carbopol, lecithin, propylene glycol, neosporin, vitamin E, acetate, etc..*
No
Yes
Did you undergo surgery in the last 2 weeks?*
No
Yes
Do you use skin care products containing retin-A, glycolic acids, alpha-hydroxy acid?*
No
Yes
Do you exfoliate your skin regularly?*
No
Yes
Please list any medications you are currently taking
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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