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MICROBLADING CLIENT CONSENT FORM

-personal & confidential- 

MICROBLADING CONSENT & AGREEMENT

Microblading is a semi-permanent cosmetic tattooing technique that enhances the appearance of eyebrows by creating natural-looking hair strokes.

I understand and acknowledge that I am of the full age of 18 years or older. If below 18 years of age a parent or guardian must also sign this form. I confirm that I am not under the influence of alcohol or any illicit or prescription drugs which would in any way impair my ability to agree to the terms of this agreement or safely commence the procedures herein. This agreement will remain in effect for this procedure and all future procedures conducted by my technician or any other technician conducting business at Refined by Riley I understand that this agreement is binding and that I have read and fully understand all information above.

MICROBLADING CONTRAINDICATIONS

A contraindication is a condition that labels the client as unfit for this treatment. Please consult with me before the procedure if you have any of the following:

MICROBLADING IS NOT RECOMMENDED FOR CLIENTS WHO ARE OR HAVE ANY OF THE FOLLOWING:

  1. Pregnancy and Breastfeeding
  2. Diabetes
  3. Autoimmune Diseases
  4. Hemophilia or Blood Disorders
  5. Skin Conditions: Active skin conditions in the eyebrow area, such as eczema, psoriasis, or dermatitis, can interfere with the microblading process and lead to poor results or complications.
  6. Allergies to Pigments or Topical Anesthetics: Allergic reactions to pigments or numbing agents used during the procedure can lead to adverse outcomes.
  7. Chemotherapy or Radiation Therapy
  8. Accutane or Retin-A Use: Recent use of these medications can thin the skin and increase the risk of adverse reactions.
  9. Recent Facial Treatments
  10. History of Keloid Scarring
  11. Sunburn or Tanning
  12. Recent Cosmetic Procedures: Recent cosmetic procedures in the eyebrow area, such as waxing, threading, or tinting, may need to be avoided before microblading to ensure optimal results.

MICROBLADING CONSENT &  AFTERCARE   

The client must read and agree to the following. The client is in full understanding and is informed about this form assuming all liability.

During and after the procedure there may be temporary swelling, redness, and itching.

I Agree

During depending on this skin structure after the first treatment a small scab with a loss of hair may occur and color intensity may change.

I Agree

In the first 7 days eyebrows are up to 40% darker and 10% to 15% thicker. For example color reflection depends on the natural skin pigment.

I Agree

The pigment is absorbed differently due to the differences in skin quality thus there is no warranty for the treatment success.

I Agree

The shape is determined according to the face proportions.

I Agree

Depending on the skin structure it should be noted that changes in the color intensity is possible and that one or more additional treatments will be required.

I Agree

The minimum or maximum duration a microblading, Microshading, and permanent makeup procedures cannot be determined with certainty nor warranty.

I Agree

Touch up fees may apply for future appointments. if most of the color has faded then this will not be considered a touch up and all fees for a new service may apply. touch ups are usually performed after 6 to 8 weeks for oily skin it maybe necessary to perform more corrections.

I Agree

Permanent make up always leads to skin injury therefore it is important to carefully and gently nurture your skin after the treatment to allow healing without complication inadequate care. improper care of face and skin can lead to poor results and your technician cannot be liable for it.

I Agree

Keep your eyebrows dry and clean for the next 10 days.

I Agree

Do not wet brows with water. (A thick crust can appear and all the pigment will fade)

I Agree

Do not touch the scab in any case except while cleaning.

I Agree

If skin is oily or sweaty make sure you clean the skin when necessary witch hazel if necessary.

I Agree

Please do not use any other creams except the ones provided or recommended to you in order to prevent a possible infection or allergic reaction.

I Agree

In the first 2 weeks after the treatment avoid swimming pool, sunbathing, tanning beds (for 50 days), sauna, beauty treatment and intense training accompanied by sweating (sports activities), or contact with dirt or dust.

I Agree

Your technician is not liable in case of an improper post-treatment care.

I Agree

I understand the service refund policy that states there is no refunds given for any service.

I Agree

I knowledge that no guarantees were made to me concerning the results of this procedure.

I Agree

I confirm that I have read and understood the above mentioned information.

I Agree

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin procedures, it may result in adverse reactions.

I Agree

I give consent to perform the microblading procedure and accept the potential complications and consequences involved with this service and waive any liability relating to such a reaction.

I Agree

By signing below, I verify that I have read and understand the above statements and agree to them.

RISKS OF PROCEDURE:

I understand there are risks associated with permanent makeup, including but not limited to: infection: Procedures which involve penetrating the skin could cause infection; Scarring: Recovery from the procedure(s) could lead to scaring; Allergic reaction: pigments, dyes, or other materials used could cause a reaction; Color: Colors will vary based on skin tone, pigments, dyes, or other materials could cause a reaction; Colors will vary based on skin tone, pigments may fade over time; irregularity: Pigments may fan or spread causing makeup lines to blue; Permanence: Permanent makeup is intended to produce long-lasting changes to appearance which may be difficult or impossible to modify or remove. 

Other Treatment: I understand that if I have any skin treatments, including, but not limited to laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable. 

WAIVER, RELEASE OF LIABILITY AND INDEMNITY

I, in consideration of Riley Davidson and Refined by Riley completing the procedure(s) mentioned below, hereby release and further agree not to make any claim or demand, or commence legal action against Davidson for damages, compensation, loss or any relief whatsoever in respect of any cause or matter relating to the procedure(s). I further agree that this Agreement shall operate conclusively as an estoppel in the event any such claim, action or proceeding and may be pleaded accordingly.

 I accept full responsibility for and indemnify and hold Refined by Riley harmless and without liability of any kind whatsoever for the responses to products used for Microblading. Refined by Riley will not be held responsible for any injury or damage that may occur due to Microblading.

I further agree to hold Refined by Riley nameless and harmless from any and all damages. I release Refined by Riley from any responsibility for pre-existing conditions I have not revealed, or any consequential change to those conditions that arises after the procedure. I understand I am responsible for any medical treatment I may need to receive because of getting this procedure. I accept full responsibility for these and any other complications, which may arise or resulting of getting this procedure(s), which are to be performed at my request.

Having read the above, I acknowledge that all of procedures contemplated and consented to herein have been fully explained and I fully understand the nature, scope and potential risks of the procedure(s) I am consenting to being performed and accept full responsibility for any and all results of the said procedure.

PHOTOGRAPHIC, AUDIO, OR VIDEO RECORDINGS MAY BE USED FOR THE FOLLOWING PURPOSES:

I hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded in audio or video tape without payment or any other consideration.

I understand that my image may be edited, copied, exhibited, published, or distributed. I waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any rights to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

PHOTOGRAPHIC, AUDIO, OR VIDEO RECORDINGS MAY BE USED FOR THE FOLLOWING PURPOSES:

  •  Educational videos
  •  Promotional materials

By signing this release, I understand the permission signifies that photographic or video recordings of me may be electronically displayed via internet.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree. I hereby release any and all claims against any person or organization


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
How did you hear about us?

How did you hear about us? *
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

Age: *
Hemophilia *
No
Yes
Diabetes Mellitus *
No
Yes
Hepatitis a,b,c,d,e *
No
Yes
HIV *
No
Yes
Skin diseases *
No
Yes
Eczema *
No
Yes
Allergies*
No
Yes

If yes, please explain:
Auto immune disease *
No
Yes
Do you have problems healing of wounds*
No
Yes
Are you prone to herpes *
No
Yes
Infectious disease/high fever *
No
Yes
Epilepsy *
No
Yes
Cardiovascular problems *
No
Yes
Are you taking any medication for blood thinning *
No
Yes
Are you pregnant or nursing*
No
Yes
Are you taking medication on a regular basis*
No
Yes
Do you have a pacemaker *
No
Yes
Have you consumed any drugs in the last 24hrs*
No
Yes
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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