MICROSHADING CONSENT FORM

Microshading/Ombre: DISCLOSURE & CONSENT FORM

I, as a client have requested that you describe the procedure to the utilized so that I may make an informed decision whether or not to undergo the procedure.

You have described the recommended procedure to be used as Microshading/Ombre, the process of implanting micro insertions of pigment into the upper dermal layer of skin. Microshading/Ombre is a form of tattooing used for the purpose of eyebrow enhancement.

I voluntarily request as my intradermal cosmetic artist and such association and technical assistance as he/she may deem necessary to perform Microshading/Ombre.

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I hereby authorize Eyemixx Lashes & Beauty to take photographs of the work performed both before and after treatment, and I further authorize the use of said photographs to be used for the purpose of advertising.

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I hereby authorize Eyemixx Lashes & Beauty to take photographs of the work performed both before and after treatment to be maintained only in file.

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I have informed Eyemixx Lashes & Beauty that I am in good health and not under the care of any physician.

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I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure.

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I understand that there may be known and unknown risks and hazards related to the performance of the procedure planned for me and I understand that no warranty or guarantees have been made to me as to the results.

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I acknowledge the manufacturer of the pigment to be applied requires spot testing and specifically disclaims any responsibility for any adverse reaction to applied pigments. I understand spot testing may identify individuals who develop an immediate allergic reaction to pigment;

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I understand that allergic reactions to pigment are very rare, however they can and do occur and when they occur they can be serious and especially difficult and very troublesome to treat.

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I have been told that this procedure may involve pain and discomfort.

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I understand the markings are permanent and that there is a possibility of hyperpigmentation resulting from procedure, especially in individuals prone to hyperpigmentation from a scar or other injury.

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I understand that a touch-up appointment is required. Touch-up appointments are to be done within 8 weeks of initial service. Cancellations or rescheduled of touch-ups are not permitted!!! If I become a no show or I take my appointment after 8 weeks of initial service, I acknowledge that the touch-up appointment is no longer considered “the initial fee”, but is now a fee of $150 paid at the time of service.

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Other risks involved with the procedure may include, but not limited to: infections, allergic and other reaction(s) to applied pigments, allergic and other reaction (s) to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.

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I accept full responsibility for any and all, present and future, medical treatment(s) and expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason associated with procedure planned for me.

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I acknowledge the procedure(s) to be performed and the risks and hazards involved and I believe that I have sufficient information to give this informed consent.

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I understand that this is a cosmetic tattoo and with time pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, and use of chemicals such as Retin-A and Glycolic acids. Touchup maintenance work will be expected in the future to keep it looking fresh.

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I understand that there is No Refund policy on permanent makeup. For some reason if my pigment does not stay or needs more touchups I agree to contact Eyemixx Lashes & Beauty for further discussions on additional applications. However, I am fully aware that Refunds will not be received.

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Payment is rendered upon completion of the session. In the unlikely event of a dispute, I agree to arbitration.

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I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify Eyemixx Lashes & Beauty: and I further agree that any controversy or claim arising out of or relating to the consent and/or any signed contract between myself and Eyemixx Lashes & Beauty or the breach thereof, shall be settled by arbitration in the state in accordance with Rules of the American Arbitration Association and judgment of the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

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I understand that if I have an infection, adverse reaction or allergic reaction the procedure I must notify Eyemixx Lashes & Beauty, a health care practitioner, State Department of Health, Drugs and Medical Devices Division.

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I certify that I have thoroughly read this form and or it has been read to me. I understand its contents.

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I understand that I must follow Post Procedure Instructions. Post Procedure & Aftercare will be given to each client at the end of each procedure.

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I have read and understand the contents of each item above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s). I was of sound mind and capable of making independent decisions for myself and that no one has coerced me into making this decision. I also agree not to hold neither Eyemixx Lashes & Beauty and/or anyone who may be assisting her/him liable for any reactions, outcomes, or occurrences that may or may not result from having this procedure(s).

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May 16, 2025

Microshading/Ombre: What to Expect

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Microshading/Ombre will appear extremely intense and thick immediately after the procedure. The color will not even look right the first few days. Other factors are added to the permanent makeup pigment bottles to counteract the undertones of facial skin. Browns can look orangish-brown, blonde brows may look too yellow, lip colors are shocking! Some colors initially look too bright and others look too dark. But don't worry - it changes. Excess pigment sheds off over the next 2-3 days, and then the skin starts healing over. A layer of healed skin on top of the pigment masks and tones it down considerably. As swelling goes down the lines will be thinner. On about the fourth day you are close to looking normal and no one notices anything. Colors will continue to soften over the next few weeks. It will look very natural in 1-2 months.

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What’s Normal with Microshading/Ombre?

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Treated area will flake

I Agree

When applying ointment pigment will come off on the Q-tip

I Agree

After the first procedure permanent makeup will appear to be thinner

I Agree

Everyone’s body chemistry is different. Depending on anti-aging products used, sun exposure, smoking habits, prescription medication, skin texture, skin complexion, and/or immune system some pigments may fade more than others. If your Microshading/Ombre, lightens, and or is nonexistent please do not panic. You have a touchup and at this touchup modifications can be made to adjust the procedure to your situation. Please note ****Microshading/Ombre is at least a 2 step process. Therefore, loss of pigment is normal with some individuals.

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Final healed result is at about 1-2 months. UNDER NO CIRCUMSTANCE WILL YOU BE ALLOWED TO GET A TOUCHUP BEFORE THIS TIME. If a touchup is needed, it is not done any sooner than 1 month after the first procedure. Performing a touchup too early could cause scarring and permanent damage to the treated area.

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Microshading/Ombre: AFTERCARE

General:

Keep the treated area moist for 7 full days following the procedure by continuing to apply, ONLY the aftercare that is provided regularly, during the day, with a Q-tip. Remember, the ointment acts as a “bandage” and keeps out dust, pollen and air. Clean area with cool water and mild antibacterial soap (Dial), and pat dry before reapplying ointment.
Do not expose treated area to sun or a tanning booth, for 2 days.
Absolutely no Neosporin, no cleansing creams, makeup or chemicals may be applied to the pigmented, treated areas for the first 3 days.
No hot, steamy, full pressure showers, saunas, excessive sweating, Jacuzzis or swimming in chlorinated pools. These things can hinder the color bonding process.
No Retin-A, bleaching creams, glycolic acids, fruit acids or AHA acids on the treated area.
If crust appears on the procedure area, do not pick or peel the crust off because color will be removed along with the crust. Do not touch the procedure area with fingers as the fingers could transmit bacteria onto the area and lead to infection. This could ultimately incur some additional expenses to you.
Don’t sleep on a nice pillowcase for the first 2 nights. Ointment and pigment can get on it.
After 7 days you may apply makeup.
If you are a blood donor you cannot give blood for 1 year. Following your procedure (Per American Red Cross.)

I understand that at the first sign of an infection, adverse reaction or allergic reaction to the procedure, I must notify Eyemixx Lashes & Beauty, a health care practitioner, and the Department of Health, Drugs and Medical Devises Division 1-888-839-6676.

Failure to follow post treatment instructions may cause loss of pigment, discoloration, or infection. Remember, colors appear brighter and more sharply defined immediately following the procedure. As the healing progresses, color will soften. A touchup procedure may or may not be necessary. Final results cannot be determined until healing is complete. Touchup procedures must be done between 30-60 days following the procedure. Additional fees will apply for touchups after 60 days… PLEASE FEEL FREE TO CALL IF YOU HAVE ANY FURTHER QUESTIONS.

Enjoy your brows!

COVID-19 Liability Waiver

Eyemixx Lashes & Beauty is taking extra precautions with every client to include a health review and extra sanitation/disinfection procedures in accordance with CDC guidelines due to Covid-19.

Symptoms may appear 2-14 days after exposure to the virus. People with Covid-19 may experience symptoms such as:

Fever or chills

Cough

Difficulty breathing or shortness of breath

Fatigue

Muscle or body aches

Headache

Loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do NOT currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS.

I affirm that I, as well as all household members, have NOT been diagnosed with, nor been knowingly exposed to someone with Covid-19 WITHIN THE LAST 14 DAYS.

I affirm that I, as well as all household members, have not traveled outside the country, or to any city considered to be a "hot spot" for Covid-19 infections WITHIN THE LAST 14 DAYS.

I waive all liability of Eyemixx Lashes & Beauty if I contract Covid-19 during my visit for service.

I understand Covid-19 virus has a long incubation period, during which carriers of the virus may not show any signs/symptoms and still be highly contagious. It is impossible to fully determine who is positive and who is not, given the current limits of screening in this location and I accept the risks.

I have read and agree that I completely understand the terms above.

Today's Date: May 16, 2025

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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First Participant's Name

First Name*

Last Name*

Phone*

First Participant's Date of Birth*

Date of Birth

First Participant's Information

I agree to (select one): RECEIVE or WAIVE a patch test prior to application and I agree to release Nfinity Beauty, and pigment manufacture(s) from any and all liability related to allergic reaction or any other reaction to applied pigments. A patch test is the process of applying pigment to the skin in the hairline to test for an abnormal reaction. If a patch test is requested, your appointment will be delayed 3 days to allow for reaction results.*

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Company Name:

First Participant's Signature*

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Second Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Second Participant's Information

RECEIVE

WAIVE

Company Name:

Third Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Third Participant's Information

RECEIVE

WAIVE

Company Name:

Fourth Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Fourth Participant's Information

RECEIVE

WAIVE

Company Name:

Fifth Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Fifth Participant's Information

RECEIVE

WAIVE

Company Name:

Sixth Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Sixth Participant's Information

RECEIVE

WAIVE

Company Name:

Seventh Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Seventh Participant's Information

RECEIVE

WAIVE

Company Name:

Eighth Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Eighth Participant's Information

RECEIVE

WAIVE

Company Name:

Ninth Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Ninth Participant's Information

RECEIVE

WAIVE

Company Name:

Tenth Participant's Name

First Name*

Last Name*

Participant's Date of Birth*

Date of Birth

Tenth Participant's Information

RECEIVE

WAIVE

Company Name:

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*

Microblading/Ombre: MEDICAL HISTORY FORM

My procedure today is: *

Combo Brows

Microblading

Ombre Brows

Today's Date:

Work Address:

Home Phone:

Cell Phone:

Employer:

Occupation:

Are you now or have you been under the care of a physician within the last two years?*

Yes

If yes, please provide Physician's Name, address and phone number.

List all medications you are currently taking, including Retin A, Glycolic Acid and Accutane:

Select any conditions you have ever had:

Artificial Heart

Valves/Vascular Graft

Abnormal heart conditions

Anaphylaxis

Asthma

Blood Disease

Cancer

Low Blood Pressure

Liver Disease

Stomach Ulcers

Tuberculosis

Chemo/Radiation

Hepatitis

Nervous Problems

Rheumatic Fever/ Scarlet Fever

Respiratory Disease

Psoriasis

High Blood Pressure

Epilepsy

Thyroid Disturbances

Cold sores/Canker sores

Artificial Joints

AIDS/HIV Positive

Anemia/ Hemophilia

Atopic (allergy prone)

Herpes

Prolong Bleeding

Glaucoma

Stroke

Tumors/Growth/Cyst Cancer

Prosthetic Hip or Joint

Fainting

Heart Murmur

Psychiatric Care

Shingles

Skin Rash

Circulatory Problems

Diabetes

Kidney Disease

Pacemaker Heart Surgery

Organ Transplant

Please select any allergies you have:

Latex

Nickel

Lidocaine

Novocain

Benzocaine

Tetracaine

Epinephrine

Antibiotic Ointment (Bacitracin)

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

RECEIVE

WAIVE

Company Name:

Parent or Guardian's Signature*

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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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