Specials & Packages
Microblading Procedure Consent Form
Microblading Procedure Consent Form
Apt, Suite, Bldg. (optional)
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
East Timor (Timor Timur)
Papua New Guinea
Saint Kitts and Nevis
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States of America
How did you hear about Us?
Google/ Web Search
If Referral, whom?
Is this the first time you've had microblading?
If No, DId you have any reaction?
If Yes, please describe
Do you wear contacts?
Do you have, or are you currently being treated for any eye illness or injury?
What side do you predominantly sleep on?
Please list any eye medications you are using:
Are you able to keep your eyes closed and lie still for up to 2 hours or longer?
please select all that apply
Hypersensitivity to cyanoacrylate or certain adhesives/glues
Recent high fever or severe illness
Blephroplasty (eye lift)
Hemophilia or any other condition/disorder that makes you bleed easily
Drank alcohol or caffeine in the past 48 hours
Allergies to shellfish or metal
Allergies to Lidocaine or other numbing agents
Consumed pain killers or any other medications that thin the blood in the past 48 hours
Chemotherapeutic or radiation agents used in cancer treatments
Retinoids used to treat acne and other skin problems (such as Accutane or Retin A)
Beta-adrenergic blockers used to control blood pressure
Eye Surgery/ Injury/ Corneal Abrasion
Excessively oily skin
Abnormal heart condition
Allergies (If yes please list in the text box below)
Pregnant/ breast feeding
Tan by booth or sun
High tolerance to numbing agents
Other Heath conditions/concerns that may affect your getting semi-permanent make up
Allergies/ Other Health Conditions
If none, please indicate "none" or "N/A" in text area.
Please list any and all medications or vitamins you're currently taking. If none, please indicate "none" or "N/A" in text area.
Consent for Microblading/ Semi- Permanent Make up Procedure
I have agreed to have semi-permanent cosmetics performed on my skin. Before my qualified Professional can perform this procedure, I understand I must complete this agreement and provide my informed consent by signing and dating where indicated below. This form is designed to give information needed to make an informed choice of whether or not to undergo a permanent cosmetics application. Please read and initial all statements below.
Please check all boxes
I have asked any and all questions that I have and am satisfied with the answers provided by the Professional.
I understand although semi-permanent cosmetic tattooing is effective in most cases, no guarantee can be made about the length of time it may last and or desired results.
I understand that this is the process of inserting pigment into the dermal layer of the skin and is a form of tattooing and can be permanent. Typically it will fade and need touch ups to maintain desired results.
I understand that all instruments that enter the skin or come in contact with body fluids are sealed and sterilized before use and disposed of after use. Cross contamination guidelines are strictly adhered to.
I understand initially the color will appear much more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 10-50%, soften and look more natural.
1. Waiver of Liability
I understand, have reviewed and signed the risks and hazards sheet. As part of this procedure, I understand that even though the Professional uses all safety procedures to ensure my procedure goes properly, I understand these risks and hazards listed on sheet are still possible. I also understand there is more than one technique for semi-permanent techniques and that results will vary from person to person, and I will not attribute any liability to Professional or the salon, as a result of this procedure or the use and care of these lashes. I also agree to defend, indemnify and hold harmless Professional and the salon from any and all claims, actions, expenses, damages and liabilities, including reasonable attorneys’ fees, which might be asserted against them as a result of my having this procedure performed. As used in this agreement, the terms “Professional” and “the salon” include all of their respective officers, directors, agents, employees, successors and assigns.
2. Waiver of Patch Test.
I understand the risks associated with semi-permanent cosmetics and I am willingly forgoing the patch test and accepting full responsibility of any and all reactions associated with the procedure.
3. Care and Maintenance
I have reviewed and agree to follow the care and maintenance instructions provided by the Professional for the use and care of my semi-permanent cosmetics, and that if any follow up care is required due to my own mistake or negligence, or failure to follow these instructions, this will be at my own expense and risk.
4. No Known Medical Conditions/ Informed Consent
I have read and completed the Client Intake Form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the Professional’s instructions or these warnings. If any action is brought to enforce the terms of this agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this agreement will be resolved through binding arbitration using the rules of the American Arbitration Association. This agreement will remain in effect for this procedure, and all future procedures conducted by the professional listed above or any other professional conducting business at the salon/spa establishment listed above. I agree that this agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this agreement, and will provide a copy of my photo ID for the Profession to verify and keep in my file. I understand my signature below, ratifies and consents to this procedure under these terms
5. Permission to Use Pictures.
I hereby grant to Professional the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary by Professional. I further expressly assign any copyright in these photographs to the Professional. I also grant my consent for Professional to use my image and likeness as contained in these photographs for any advertising or other purposes, along with any comments I may provide
By submitting electronic signature below, I understand and adhere to all of the above.
Enter full name
Please enter any two digits
This box is for spam protection -
please leave it blank
127 E Intercity Ave
Everett, WA 98208
Raves and Reviews
Copyright 2017 © My Beauty Escape LLC, Beauty Escape Spa LLC
Website Developed by
Icon Web Development