CONFIDENTIAL FORM

Have you received a Microblading Service before at Paola Tonini Beauty Studio?*

How did you hear about us?*

Consent and Release Agreement

This form has been designed to provide the necessary information for individuals to make an informed decision regarding the potential undertaking of Microblading procedure, which involves the application of semi-permanent makeup. Should you have any inquiries, please do not hesitate to seek clarification.

While Microblading is generally effective, it is important to note that no guarantee can be provided regarding the specific benefits an individual client may derive from the procedure.

This process entails the insertion of pigment into the basal layer of the epidermis, constituting a form of semi-permanent tattooing. It is imperative to highlight that all instruments that come into contact with the skin or body fluids are disposable and are disposed of after single use. Adherence to strict cross-contamination guidelines is paramount.

In most cases, the outcomes of the procedure are excellent. Nevertheless, it is crucial to understand that attaining a perfect result is not a realistic expectation. It is customary and advisable to anticipate the need for a touch-up after the completion of the healing process.

Initially, the color may appear more vibrant or darker compared to the final outcome. Typically, within a span of 5-7 days, the color will fade by approximately 40-50%, leading to a softer and more natural appearance. As the pigment used is semi-permanent, it will gradually fade over time. Additional touch-up sessions are likely to be required within a period of 6 months to 2 years.

I hereby certify that I have either read the contents of this form or had them read to me. I comprehend the risks and alternatives associated with this procedure. I have been given the opportunity to pose any questions I may have had, and all of my queries have been adequately addressed. I acknowledge that I have reviewed and given my approval to the material provided, and I authorize Paola Tonini Beauty Studio to proceed with the Microblading procedure on my desired body area today.

Statement of Consent and Recitals

Please carefully read and initial each line*:

I have received thorough aftercare instructions, both verbally and in written form, which I will retain and diligently follow to the best of my ability. In case of any inquiries, I will contact Paola Tonini beauty studio via phone or email. I attest to having reviewed the “PRE-APPOINTMENT INFORMATION” relevant to my intended procedure and confirm my eligibility for treatment.

I am aware that a certain degree of discomfort is associated with this procedure, and it is possible to experience swelling, redness, and bruising.

I understand that the use of Retin-A, Renova, Alpha Hydroxy, and Glycolic Acids on the treated areas is strictly prohibited. These substances can alter the color and cause premature fading of the pigment.

I acknowledge that activities such as tanning beds, swimming pools, certain skincare products, and medications may have an impact on the longevity of my permanent makeup.

I understand that due to the presence of hidden scar tissue, it is not possible to guarantee complete color saturation.

It is my responsibility to clearly communicate my desired colors, shape, and placement for the procedure being performed today.

I am aware that the implanted pigment may undergo slight changes or fading over time due to factors beyond the control of the practitioner. I acknowledge that maintaining the desired color may require future applications and a touch-up session within 60 days.

I recognize that the proposed procedure(s) carry inherent risks, and complications such as infection, misplaced pigment, poor color retention, and hyperpigmentation are possible during and/or after the procedure.

I have been advised that scheduling a touch-up session is highly recommended to make any necessary adjustments to shape, color, and address any areas where the pigment has not retained well. Touch-ups must be scheduled within 30-45 days of the initial procedure.

I have been provided with a cost estimate for today’s appointment as well as the touch-up session. To be considered a touch-up service, the touch-up must be completed within 30-45 days of the initial procedure.

I certify that I have personally read the contents of this form or have had them read to me. I have a clear understanding of the risks involved in the procedure(s) and the available alternatives. All of my questions have been addressed to my satisfaction. I acknowledge that I have thoroughly reviewed and approved the materials provided to me. Accordingly, I authorize Paola Tonini Beauty Studio to perform the desired Microstroking procedure (Microblading) on my body today.

Photography Release Consent

We kindly request your authorization to utilize the provided photos for advertising purposes, such as inclusion in portfolios, online promotions, print advertisements, and similar media. Your explicit consent is essential in this regard. To indicate your preference regarding the usage of your photos in advertising, please provide your signature below.

Possible Risks, Hazards, or Complications

Pain: It is important to note that despite the application of topical anesthetics, some individuals may still experience discomfort. The effectiveness of anesthetics can vary among different individuals.

Infection: The likelihood of infection is extremely rare. To ensure a clean and hygienic healing process, it is crucial to maintain proper cleanliness of the treated areas and only touch them with freshly cleaned hands. Detailed instructions on aftercare can be found in the provided “Aftercare” sheet.

Uneven Pigmentation: Uneven pigmentation can occur due to factors such as inadequate healing, infection, bleeding, or other causes. It is highly probable that any uneven appearance can be addressed and corrected during your follow-up appointment.

Asymmetry: While every effort will be made to achieve symmetry, it is important to recognize that our facial features are inherently asymmetrical. Adjustments may be necessary during the follow-up session to correct any noticeable unevenness.

Excessive Swelling or Bruising: The extent of swelling or bruising can vary from person to person. Applying ice packs can help reduce swelling, which typically resolves within 1-5 days. It is worth mentioning that some individuals may not experience any bruising or swelling at all.

Anesthetics: Topical anesthetics are employed to numb the tattooed area. These may include Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid. If you have any known allergies to these substances, please inform me immediately.

MRI: In the event that you require an MRI scan, it is important to inform the MRI Technician of any tattoos or permanent cosmetics present, as the pigments used in these procedures contain inert oxides. In some cases, a low-level magnet may be necessary. Alternatively, if you have concerns regarding MRI compatibility, you may choose to opt for traditional cosmetics and forego the semi-permanent eyebrow procedure.

Please provide your consent and release for the procedure performed.

Have you ever experienced or currently have any of the following medical conditions?*

Abnormal Heart Condition

Accutane or acne treatment

Alcoholism

Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.

Allergies to metals, food.

Allergies not listed?

Any diseases or disorders not listed?

Autoimmune disorder

Botox (Last treatment)

Cancer

Chemical Peel (Last Treatment)

Brow Lash Tinting

Chemotherapy/Radiation

Diabetes

Difficulty numbing with dental work

Do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?

Are you taking any medications?

Currently Pregnant or Breastfeeding

Easy Bleeding

Forehead/Brow Lift/Facelift

Hepatitis A BC D

History of MRSA

Oily Skin

Take medication before dental work

Tan by booth or salon

Tumors/Growth/Cysts

Taking blood thinners such as Aspirin, Ibuprofen, Alcohol, Coumadin, etc.

I agree that all the above information is true and accurate to the best of my knowledge

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