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Nicolette Koshaba Artistry LLC
2507 Mineral Springs Ave Ste C
Knoxville TN 37917

May 20, 2025

I certify that I am over the age of 18, and I am not under the influence of drugs or alcohol. I consent to receiving the indicated micro-pigmentation cosmetic procedure. The general nature of cosmetic tattooing, as well as the specific procedure to be performed, has been explained to me via microbladingbynicolette.com and/or verbally with my artist.


I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, cold sores, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure/s, and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure/s.


I have received pre- and post-procedure instructions via microbladingbynicolette.com. I have received a physical aftercare protocol instruction card and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. I understand that my artist is able to deny any follow-up appointment, if finding the aftercare is not being adhered to/home or professional removal was performed.


I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done and understand that there is a NO REFUNDS policy. 




I understand that if I no-call-no-show to my appointment, I forfeit the entire cost of procedure.




I understand that one (1) touch-up is included in the cost of the initial procedure with 6-12 weeks. I understand that I forfeit my complementary touch-up session if not booked within this time period, or otherwise agreed upon with my artist. I understand that annual touch-ups are completed between 9-18 months. I understand it is under the discretion of my artist whether the original work is too faded, if past the 18 month mark. 




I understand that if I show up 15 or more minutes late, I forfeit the entire cost of the procedure, unless communicated with and otherwise agreed upon by my artist. I understand that if I cancel less than 24 hours before my scheduled touch-up, it is under my artist's discretion whether or not I am able to reschedule. I understand that if I must reschedule my touch-up, it is permissable up to one (1) time. In other words, if cancelling two (2) touch-ups consecutively, I forfeit my touch-up and may not be eligible for an annual procedure.




I understand that if I show up to my appointment 15 or more minutes late, it is under my artist's discretion whether or not she/he will still perform the procedure, and the entire procedure amount is forfeited, if not able to procede.


I understand that these appointments take considerable time, and 72 hours of notice is required to reschedule an appointment. If a client cancels with less than 24 hours notice, the full procedure amount may be automatically forfeited.


I understand that there will be an additional $50 fee will be applied to rebook when cancelling within 24 hours or less. 


I understand that all annual touch-ups will be performed at Nicolette Koshaba Artistry LLC HOME location in Knoxville or surrounding area, unless agreed upon with my artist. 



I understand that once a person has contracted herpes virus, it remains dormant in the system throughout their lifetime and will become active if the immune system is compromised. I understand that if I have had a cold sore in the past, Nicolette Koshaba Artistry LLC advises receiving a script from my doctor for an anti-viral oral medication prior to any lip procedure as a preventative. Another option is to purchase an over-the-counter anti-viral cream called acyclovir ointment and apply to the area as follows: 5 times a day for 5 days pre-treatment and 5 times a day for 5 days post-treatment. I understand that regardless of having had history of cold sores, we recommend all clients take l-lysine (vitamin) 2 weeks before the appointment and 2 weeks following the appointment to reduce the risk.



I consent to before and after photos being taken for personal or promotional use. For external not-for-profit educational purposes outside Nicolette Koshaba Artistry LLC, such as lectures, presentations at professional conferences, news publications, website publications, social media posts, and email blasts.



 

May 20, 2025

 

Additional Treatment Policy

We reserve the right to refuse services to anyone.

Two or more appointments may be necessary to achieve and complete most permanent makeup procedures depending on each person’s skin. Touch-up fees may apply.

I have read, understand, and agree to all of the Policies listed above.

May 20, 2025

 

I have read and understand the information. I hereby release Nicolette Koshaba Artistry LLC, its personnel, and any other persons participating in my care from any and all liability.

May 20, 2025



First Client's Name
First Name*
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Third Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Fourth Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Fifth Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Sixth Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Seventh Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Eighth Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Ninth Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
Date of Birth
Tenth Client's Name
First Name*
Last Name*
Phone*
Client's Date of Birth*
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*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Medical and Client History
Easy bleeding/hemophelia*
No
Yes
Pregnant/breastfeeding*
No
Yes
Eczema*
No
Yes
History of herpes (including cold sores)*
No
Yes
Chemotherapy/radiation:*
No
Less than 6 months ago
Prior to 6 months ago
Taking blood thinners*
No
Yes
Keloid scarring*
No
Yes
Difficulty numbing with dental work*
No
Yes
Oily skin*
No
Yes
Botox within the last 2 weeks*
No
Yes
Accutane or acne treatment*
No
Yes
Tanning in a tanning bed less than 2 weeks before procedure*
No
Yes
Recent chemical peel or equivalent*
No
Yes
Current use of retinoids*
No
Yes
Problems with wounds healing*
No
Yes
Do you have any diseases or allergies not listed?
Any diseases or disorders not listed*
No
Yes
What facial products do you use on a daily basis?
Please list any medications you are currently on, if any:
Do you FULLY understand that any concern/dissatisfaction must come directly to your artist at Nicolette Koshaba Artistry LLC? Do you understand that no artist from the company, or the company itself, will be slandered on any public forum or social media, otherwise legal action will be taken? Nicolette Koshaba Artistry LLC is not responsible for any later disapproval of agreed upon shape, strokes, services, etc. Do you understand that you are electing to have this service done unto yourself at your own risk/reward?*
No
Yes
Do you understand that you are FULLY responsible for notifying your artist of any future changes to your medical and client history?*
No
Yes
Please provide a description of the body art being provided:
Location on body that body art will be provided:
What is the name of the artist providing your service?
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 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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