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Disclosure and Consent for Tattoo and Dermal Procedures



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

You have been described the recommended procedure to be Micropigmentation, the process of implanting pigment into the dermal layer of skin. Micropigmentation is a form of tattooing used for the purpose of permanent cosmetic makeup and skin imperfection camouflage.

  1. I understand the description is not meant to alarm me, just to make sure I'm better informed so that I may give or withhold consent for this procedure.
  2. I have informed Glow Girl Beauty Bar Paramedical Artistry that I am in good health.
  3. I understand that no warranty or guarantees have been made to me as to the results.
  4. I understand that there is a possibility of hyperpigmentation resulting from a procedure, especially in individuals prone to hyperpigmentation from a scar or other injury.
  5. I have been told that there may be risks and hazards related to the performance of the procedure planned for me.
  6.  I have been told that this procedure may involve discomfort or pain.
  7.  I have been told that the markings are permanent and that there is a risk of infection following the procedure.
  8.  I have been told that a follow-up procedure may be required and that the color of the pigment may fade.
  9.  I have been told that there is a fee if a "touch up" is required.
  10. I have been told that there is a chance that I may experience a cornea abrasion from the eyeliner procedure.
  11.  I have been told that there is a chance of an allergic reaction to pigment and that my body may reject the pigment.


Disclosure and Consent for Tattoo and Dermal Procedures (Continued)

I have accurately completed the Medical History Form.


 

I have been candid in revealing any condition that could prohibit or alter my treatment such as, but not limited to, pregnancy, recent surgeries, sun exposure/tanning, cold sores, tendency of scaring, breastfeeding and use of any Accutane in the past 12 months.


 

I understand that there are no guaranteed results from these treatments, many variables such as age, sun damage, prolonged sun exposure, smoking, excessive alcohol intake, climate, diet and increased water intake may reduce the effects of my treatment.


 

Regardless of precautions taken, I acknowledge the possibility of an adverse reaction to the treatment and accept sole responsibility for any medical care that may become necessary. I will immediately inform the Doctor or Technician performing the treatment, of any adverse reactions.


 

In the application and removal process of permanent make-up the epidermal layer to skin is penetrated. Some of the potential side effects include but are not limited to: discomfort, swelling, reddening, hyper-pigmentation, hypo-pigmentation, eye injury, scarring and infection.


 


I understand that there is a chance for pigment migration. This is where the pigment moves out of the designated area being treated to an area where pigment may not be desired.


 

 I agree that should I have a complaint of any kind whatsoever, I shall immediately notify Rebecca Matthews and further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and Rebecca Matthews or the breach thereof, shall be settled by arbitration in the state of California in accordance with the 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.


 

 I understand that If I have an infection, adverse reaction, or allergic reaction to the procedure, I must notify Rebecca Matthews immediately and seek medical attention immediately.


 

 I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it, or it has been read to me. I understand it's contents.


 

 Upon signing this form, I acknowledge that I have read this form, that I fully understand it's contents and that I have been given ample opportunity to ask questions and that all of my questions have been answered to my satisfaction.


 

Today's Date: July 27, 2024


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Parent or Guardian's Information
I voluntarily request my Medical Micropigmentologist, Rebecca Matthews, to perform the following procedure(s):
Microblading
Eyebrow Tattoo
Eyeliner Tattoo
Lip Tattoo
Areola Tattoo
Scalp Tattoo
Removal
Scar Camo

PLEASE READ AND CHECK ONE:

I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, and further authorize the use of said photographs for her website, social media and/or to show future patients. (She is able to conceal your identity if requested)
I authorize Rebecca Matthews to take photographs of the work performed both before and after treatment, to be maintained only in my file.
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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