CONSENT AND RELEASE AGREEMENT FOR PERMANENT

CONSENT AND RELEASE AGREEMENT FOR PERMANENT COSMETICS

This form is designed to give information needed to make an informed

choice of whether or not to undergo a permanent cosmetics application.

If you have questions, please don’t hesitate to ask.

Although permanent cosmetic tattooing is affective in most cases, no

guarantee can be made that a specific client will benefit from the

procedure.

This is the process of inserting pigment into the dermal layer of the skin

and is a form of tattooing.

All instruments that enter the skin or come in contact with body fluids

are sealed a sterilized before use and disposed of after use. Cross

contamination guidelines are stickily adhered to.

Generally, the results are excellent. However, a perfect result is not a

realistic expectation. It is usual to expect a touch-up after the healing is

completed.

Initially the color will appear much more vibrant or darker compared to

the end result. Usually within 57 days the color will fade 10-50%, soften

and look more natural. The pigment is permanent but will fade

somewhat over time and will likely need to be touched-up through the

years.

PHOTOGRAPHY AND VIDEOGRAPHY RELEASE CONSENT

Our insurance company requires “Before” and “After” photos/videos be

taken and kept on file. We would like your permission to use these

photos/videos for advertising. For example, in portfolios, online and in

print adds, etc. Your consent is necessary regarding this. Please circle

and indicate with your signature if you would like your photos/video

used or not used in advertising.

YES, feel free to use them NO, please do not use them

Signature _______________________________________ Date________________________

Special requests, concerns or remarks for technician:

Gloss Nail Spa

POSSIBLE RISKS, HAZARDS OR COMPLICATIONS

 Pain: There can be pain even after the topical anesthetic has been used.

Anesthetics work better on some people than others.

 Infection: Infection is very unusual. The areas treated must be kept clean an

only freshly cleaned hands should touch the areas. See “After Care” sheet for

instructions on care.

 Uneven Pigmentation: This can result from poor healing, infection,

bleeding or many other causes. Your follow up appointment will likely

correct any uneven appearance.

 Asymmetry: Every effort will be made to avoid asymmetry but our faces are

not symmetrical so adjustments may be needed during the follow up session

to correct any unevenness.

 Excessive Swelling or Bruising: Some people bruise and swell more than

others. Ice packs may help and the bruising and swelling typically

disappears with 1-5 days. Some people don’t bruise or swell at all.

 Eye Exposure: There is small risk of eye injury when an eyeliner procedure

is performed. To avoid corneal abrasion, Celluvisc, a thick eye drop is used to

protect the eye prior to the procedure. Eye drops are used to cleanse and

flush the eye after the procedure is complete.

 Anesthesia: Topical anesthetics are used to numb the area to be tattooed.

Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or

gel form are typically used. If you are allergic to any of these please inform

me now.

 MRI: Because pigments used in permanent cosmetic procedures contain

inert oxides, a low level magnet may be required if you need to be scanned by

an MRI machine. You must inform your technician of any tattoos or

permanent cosmetics.

 Fever Blisters: If you are prone to cold sores or fever blisters, (herpes

simplex), there is a high probability that you will get them. It is advised that

you call your doctor for a prescription antiviral to help prevent this form

occurring.

 Allergic Reaction: There is a small possibility of an allergic reaction. You

may take a 5-7 days patch test to determine this.

Please initial to: Waive_________ or Take_________.

The alternative to these possibilities is to use cosmetics and not undergo the

Permanent Cosmetics procedure. Consent and release for procedures

performed:

Signature _______________________________________ Date ________________________

Gloss Nail Spa

STATEMENT OF CONSENT AND RECITALS

Please read and initial all lines

_____ Aftercare instructions have been explained to me and a written

copy will be given to me to retain in my possession, which I will follow

to the best of my ability. If I have questions I will call or email you.

_____ I understand that a certain amount of discomfort is associated with

this procedure and that swelling, redness and bruising may occur.

_____ I understand that sun, tanning beds, pools, some skin care products

and medications can affect my permanent makeup.

_____ I will tell all skin care professionals or medical personnel about my

permanent makeup procedures, especially if I’m schedule for an MRI.

_____ I accept the responsibility for explain to you my desire for specific

colors shape, and position for any procedure done today.

_____ I understand that implanted pigment color can slightly change or

fade over time due to circumstances beyond your control and I will need

to maintain the color with future applications and a touch up session

within 60 days.

_____ I acknowledge that the proposed procedure(s) involved risks

inherent in the procedure and have possibilities of complications during

and/or following the procedures such as: infections, misplaced

pigment, poor color retention and hyperpigmentation.

_____ I have been quoted the cost of today’s appointment, which includes

one (1), touch up after 30 days and within 60 days. After 60 days a fee

will apply and there will be no refunds for this elective procedure(s).

_____ I accept full responsibility for the decision to have this cosmetic

tattoo work done.

I certify that I have read or have had read to me the contents of this

form. I understand the risks and alternatives involved in this

procedure(s) and I have had the opportunity to ask questions and all of

my questions have been answered. I acknowledge that I have reviewed

and approved the material given to me and I authorize

________________________________________________, as my permanent cosmetics

technician to perform on my body the following procedures.

Signature _______________________________________________ Date ____________________________

Gloss Nail Spa

AFTERCARE

After care is very important for producing a beautiful and lasting result.

 Keep the area clean by washing with freshly washed hands and a

mild soap. Do not use a washcloth or sponge to remove soap.

Simply splash with water. Do not use cleansing creams, acne

cleansers or astringents. Use a mild, natural soap.

 Apply the aftercare balm with freshly washed hands or a Q-tip. If

the balm is too stiff to use simply warm it up in a glass of warm

water or on your finger. Use the balm very sparingly. Too little is

better than too much. Blot off excess with a clean tissue. Never

touch the procedure area without washing your hands

immediately before.

 Do not scrub, rub or pick at the epithelial crust that forms. Allow

it to flake off by itself. If it is removed before it is ready the

pigment underneath it can be pulled out.

 Do not use any makeup near the procedure area including

mascara for eyeliner procedures for at least 3 days. Purchase new

mascara and makeup if possible to avoid contamination or

bacterial infection.

 Always use a sun block after the procedure area is healed to

protect from sun fading.

What’s Normal?

 Swelling, itching, scabbing, light bruising and dry tightness.

Ice packs are a nice relief for swelling and bruising. Aftercare

calm is nice for scabbing and tightness.

 Too dark and slightly uneven appearance. After 2-7 days the

darkness will fade and once swelling dissipates unevenness

usually disappears. If they are too dark or still a bit uneven after 4

weeks then we will make adjustments during the touch up

appointment.

 Color change or color loss. As the procedure area heals the

color will lighten and sometimes seem to disappear. This can all

be addressed during the touch up appointment and is why the

touch up necessary. The procedure area has to be completely

healed before we can address any concerns. This takes at least

four weeks.

 Needing a touch up months or years later. A touch up may be

needed 1 to 5 years after the initial procedure depending on your

skin, medications and sun exposure. We recommend a touch up

30 days after the first session (included in today’s price) and

every few years to keep them looking fresh and beautiful. Touch

up sessions after 60 days will be $195 or current touch up rate at

time of touch up.

Failure to follow after care instructions may result in infections,

pigment loss or discoloration.

I have read, understand and agree to the above instructions.

Signature ________________________________ Date _______________________

Gloss Nail Spa

Client Medical History Form Date _____________________

First name: ________________________ Last name: _______________________

Birthdate: _________________________

Address:_________________________________________________________________

City: ___________________________ State: _____________ Zip: ________________

Phone number: _____________________ Email: __________________________

Emergency contact:

Person: _______________________________ Phone: _________________________

Do you presently have or previously had any of the following:

(Circle YES or NO)

YES NO Botox

YES NO Diabetes

YES NO Lip Fillers/Restylane/Juve derm

YES NO Cold Sores/Fever Blisters ever?

YES NO Blepharoplasty (Eyelid surgery)

YES NO Hepatitis (A, B, C, D)

YES NO Brow lift

YES NO Easy bleeding

YES NO Face lift

YES NO Alcoholism

YES NO Eye surgery/injury/Corneal abrasion

YES NO Abnormal Heart Condition

YES NO Contact Lenses now

YES NO Chemical Peel (last treatment ______________________________)

YES NO Pregnant now/Breast feeding now

YES NO Brow or Lash tinting

YES NO Oily Skin

YES NO Accutane or acne treatment

YES NO Tan by booth or sun

YES NO Difficulty numbing with dental work

YES NO Taking blood thinners such as: Aspirin, Ibuprofen,

alcohol, Coumadin, etc. _________________________________________________

YES NO Allergic reaction to any medications such as Lidocaine,

Benzyl alcohol, Vitamin E Acetate, etc.

LIST ______________________________________________________________________

YES NO Allergies to metal, food, etc.

LIST ______________________________________________________________________

YES NO Any diseases or disorders not listed?

LIST ______________________________________________________________________

YES NO Do you use skin care products containing Retin-A,

glycolic acid or alpha hydroxyl?

Please list medications or vitamins you are presently taking:

____________________________________________________________________________

I agree that all the above information is true and accurate to

the best of my knowledge.

Signature __________________________________ Date ______________________

Gloss Nail Spa

BEFORE AND AFTER YOUR TREATMENT

Before your treatment

Prior to your permanent cosmetic enhancement think about the look

that you wish to achieve. As experts in the field of color analysis and

makeovers, we ensure that the correct colors and styles are chosen for

you, however you are part of the decision making process.

Permanent cosmetic enhancements normally require multiple

application sessions. To achieve the best results, you will be required to

return for at least one control procedure four to six weeks after the

initial application.

Be prepared for the color intensity to be significantly sharper and

darker immediately after the procedure. This will subside and become

softer as the skin heals. This process can take up to fourteen days.

-Since delicate skin or sensitive areas may be swollen or red, you are

advised not to make social plans on the day of your enhancement.

-Please wear your normal make-up to your enhancement appointment.

-Do not take aspirin or Ibuprofen 2 days prior to and after your

enhancement.

-A sensitivity test will be performed unless waived upon request.

-Do not use Retin-A skincare products close to the enhancement area 2

weeks prior to and after your procedure.

-As with electrolysis the National Blood Service does not accept

donations of blood for 1 year after a permanent cosmetic enhancement.

Eyebrow Enhancement

-Waxing treatments should be performed no less than 3 days prior to

your enhancement.

-IPL laser hair removal should be performed no less than 2 weeks prior

to your enhancement.

-Electrolysis treatments should be performed no less than 5 days prior

to your enhancement.

-Eyebrow tinting should not be undertaken for 2 weeks after your

enhancement.

After your treatment

The area treated may show redness and swelling and that the color

looks dark and intense—this is quite normal.

Additional treatments cannot be undertaken until the area has

completely healed. A 4/6 weeks healing time is required before any

more work can be undertaken.

In order to let your brows heal well, avoid water on the brow area;

make up to the brow area, the gym, sauna or pool for 7 days.

Once the area has healed completely, approximately one week, consider

using a waterproof total sunblock when going out in the sun to stop the

color fading.

Strong chemicals or glycolic acid/peels of any kind may cause the

pigment to lighten. Always telephone and check with your consultant if

in any doubt.

Do not pick or pull at the treated area, as it will result in pigment loss.

You will go through three healing phases: 1-healing, 2-peeling, and 3-

fadeing.

You may notice whiteness or blanching around the area, this is quite

normal and will subside within 12 hours. If you find any lymphatic fluid

or blood weeping you can gently clean the area with saline, cool boiled

water and gauze, blotting gently dry to remove any moisture.

With clean hands and cotton pad apply a fine layer of aftercare balm to

the treated area. Repeat this procedure up to 3 times a day if the area

feels tight.

After the fine scabbing has sloughed away you will see a different hue to

the color implanted.

 Giving Blood- The Red Cross has suggested that you do not give

blood for 6 months following treatment.

 MRI Scans- This procedure shows up as an artifact on the scan.

Some clients may experience a tingling sensation. Please notify

your radiologist.

 Injectable- Dermal fillers and Botox can alter the shape of the

eyebrows. The client should be advised that injectable should be

carried out after a Micorblading procedure and not prior.

 Laser/Pulsed Light- Laser or pulsed light hair removal or skin

rejuvenation treatments can cause color change. It is important to

advise the therapist that you have had Microblading procedure, as

this cannot be rectified with another Microblading procedure.

 Color Refreshing- To keep your new brows looking at there best,

it is recommended that you have a color refresh procedure every

12-18 months.

Gloss Nail Spa

Frequently Asked Questions

1. Are you certified?

Yes, I am Certified Permanent Makeup Artist.

2. What is 3D Eyebrow Microblading?

It is a semi-permanent makeup method; the technique is natural

feathering of hair-like strokes directly on the skin’s surface that

creates natural looking eyebrows. 3D Eyebrow Microblading creates

the background and fills in the areas of the eyebrows that looked

empty so that a full and complete look is accomplished. The “3D”

effect added realism to the end result. Unlike a traditional eyebrow

tattoo, 3D Eyebrow Microblading does not leave a flat, dull and fake

look that tattoos leave behind an is a MUCH SAFER treatment. The

3D Eyebrow Microblading method can fill in sparse brows or create

an entire brow, which makes it the perfect procedure for Men and

Women.

3. Does it hurt?

We get mix reviews on pain. Everyone has a different level of

sensitivity so topical anesthetics are applied before and during the

treatment to alleviate any sensation or discomfort. Some clients

naturally feel one brow sorer than the other. You will hear a scratch

noise/ sensation throughout.

Music is usually played during the procedure; however feel free to

bring your own earphones and music to distract you.

4. Is it safe?

Absolutely. Sterilized, disposable needles and supplies are used

during the process.

5. Will I be swollen?

You will not be swollen. You might have slightly red skin around the

eyebrows, but this would last no more than 1 hour.

6. Will I need a touch up?

Most likely. Within a week of your first treatment the color will fade

significantly and over the next four to six weeks can continue to fade

as much as 50%. This is considered an extremely positive

occurrence as it allows you time to reflect on your shape and color.

After this period your follow-up appointment is carried out. At this

point any changes you would like to make are discussed.

7. How often do I need a touch up?

In order to keep your eyebrows tattoo results looking fresh, we

recommend a touch up every year.

8. How long does it last?

It will last as long as it’s maintained. Untouched, the ink will last up

to 4 years.

9. Why do I need a touch up if this is semi-permanent?

Because color is implanted in the facial area there tends to be more

fluid circulation than other parts of the body. Your face sees the

most wear of any piece of you—exposure to the sun, food, facial

products—the list goes on and on. All of these things cause

permanent color to fade; this is why you need a touch up.

10. How long does it take?

The procedure takes roughly about two hours, sometimes more

sometimes less. Please allow a solid 3-hours window for your

appointment. I likely will not need that much time, but this isn’t

something I want to rush.

11. Do I need to take a day of work?

No. There’s no downtime associated with the treatment. Redness

and swelling will dissipate within an hour after. Your brows will

appear darker initially, but not so dark that you will be prevented

from your activities of daily living.

12. How long does it take to heal?

Healing time varies from individual to individual. Usually, it takes

about a week to ten days for the epithelial crust to form and slough

off. Your skin will be considered healed after that happens. Then,

the pigment takes some time o settle into the skin. A good month

should pass before I consider the process complete.

Gloss Nail Spa

13. What’s the process like?

Eyebrows tattoo is a two-step treatment, consisting of an initial

procedure and then a touch up between 4 to 6 weeks after.

After taking your before photo, I will draw the brow design in pencil

so you will get an idea of the shape and form. (Please not that

nobody’s face is totally symmetrical and you need to be realistic with

your expectations. There is no point in trying to make the eyebrows

identical or match a photo of your favorite celebrities’ eyebrows if

your face shape looks nothing like theirs.) Once we have agreed on a

final shape (ultimately it is your decision—but I will always voice my

opinion on what I think suits you aesthetically), I will shape your

eyebrows then we will decide on the color. Shortly after that, a

topical anesthetic will be administered to ensure comfort. Once you

are numb, the pigment is deposited. During healing, it’s normal to

experience some pigment loss; this is why we have the touch up in

place.

13. What can I NOT do after the procedure?

You are advised to keep the skin clean and dry—that means no

swimming, sweating or otherwise getting the area wet; no tanning or

prolonged sun exposure; no picking, peeling, scratching or rubbing

the tattoo, this may result in a loss of color and scarring. You can still

wash your hair and face once they are healed.

14. How do I extend the life of the procedure?

Your beautiful eyebrows will last longer if you apply sun block often

and avoid abrasive facial treatments in the brow area.

15. How many colors do you have?

Of the 9 main colors I use, I can blend several to achieve even more

shades to suit the client. ALL clients who have had the procedure

done will be conscious they have brows that are very obvious,

however please bear in mind, the skin has been broken to allow the

pigment settle, and healing has yet to take place. This is why I ask

you to bring your eyebrow pencil (if you use one) with you at the

appointment—so I can match the pigment to the desired HEALED

RESULT, which emerges after the crusts naturally fall off and the skin

gently exfoliates naturally itself to reveal the new brow. Clients, who

are used to having no brows for a long time, can find this few weeks

challenging. I usually advise clients who have no brows to start

wearing pencil or brow shading for some time before the process so

they get used to having a brow!

16. Do you have to shave off my own eyebrows?

No. Every attempt is made to retain all natural hair and integrate it

into the design of the permanent eyebrows. In some cases, where

shaping of the natural brow is required, a few hairs here and there

may need to be removed to create a clean and aesthetically pleasing

result.

17. I have heard some clients just do not retain pigment even

after a few visits. Could this happen?

Yes, it does happen and yes it’s true!

A third appointment is often set up so that the client has the

opportunity to return and I get the chance to review the work and

sort out any (if any) tweaks that might need to be done. Often times

the clients cancel this appointment as all is usually well, however

there are the occasional few that may need one or two extra strokes

to finish off the look. Some ladies skin may react to the trauma of the

tattooing, and the skin may try to push out the foreign body of

pigment by producing an extreme scab, so they eventually fall off

taking all the pigment with it. There is a condition called Pigment

Allergy (PPD Allergy, a condition known by dermatologists) or Auto

Immune disease symptoms (the client may not even be aware of it).

The skin would have over reacted and become super sensitive to the

pigment and reject it at any cost.

18. Can you guarantee your work?

Unfortunately, I can’t. How the skin will react is different for

everyone and many factors are to be taken into consideration. Skin

type, age, scarring, diet, stress levels, facial products used, etc. all

play a key role in how the pigment will hold, which is why it is

important to know that more than one touch up may be required.

I can guarantee that your face is important to me and that I will act in

accordance with my experience and expertise to give you my

absolute best. I can guarantee that I will strive to make you gratified

and content every time. But there are no guarantees in this industry.

Please think long and hard before you decide to go for it.

19. What if I do not like it?

Although Microblading is considered to be semi-permanent, the

procedure does allow flexibility for color or shape change to some

extent. However, I will work closely with you to endure that you are

satisfied with the proposed technique. I will allow you to have as

much control over the procedure as possible, so there is very little

room for error. If you do not like the decision you made, the Touch

Up can be cancelled and the pigmented area naturally fades away

over time. If you are not 100% sure you would benefit from this

procedure, please opt for a more temporary option.

PRICES

FREE consultation

$ 100 Deposit to book an appointment (it will be credited toward

the procedure fee)

Microblading -- $ ____________________________ (includes one touch up)

Yearly touch up (for eyebrows) -- $___________________________________

(Prices are subject to change without prior notice.)

Please read through the before and aftercare pages before setting your

consultation appointment to ensure that you are an ideal candidate for

permanent makeup. Please do not bring children or pets to your

appointments, if client does not cancel on time or show up, 50% fee will

be charged.

Gloss Nail Spa

BEFORE YOUR TREATMENT

-Do not work out the day of the procedure.

-Do not tan or have sunburned face.

-Do not take Aspirin, Niacin, Vitamin E or Ibuprofen 24 hours before

procedure.

-No alcohol or caffeine on the day of the procedure.

-No waxing or tinting 3 days before.

-Please note that you will be more sensitive during your menstrual

cycle.

AFTER YOUR TREATMENT

-No water, cleansers, creams, makeup or any other products on

treated area for 10 days.

-4-5 hours after the procedure clean the area with sterile water and

cotton pad, gauze or Q-tip and allow to air dry.

-DO NOT rub, pick or scratch the treated area. Let any scabbing or

dry skin naturally exfoliate off. Picking can cause scarring.

-Avoid direct sun exposure or tanning for 3-4 weeks after procedure.

-Avoid heavy sweating for the first 10 days.

-NO facials, Botox, chemical treatments and microdermabrasion for 4

weeks.

-Avoid sleeping on your face for the first 10 days.

PLEASE NOTE: EYEBROWS WILL APPEAR DARKER AND BOLDER DUE TO

NATURAL SCABBING AND HEALING FOR THE FIRST 10 DAYS. THIS IS VERY

COMMON FOR ALL PERMANENT COSMETIC PROCEDURES.

Permanent makeup is NOT recommended for any clients who are or

have:

-Pregnant or nursing

-Diabetic

-Undergoing Chemotherapy (consult your doctor)

-Viral infections and/or diseases

-A Pacemaker or major heart problems

-Had a organ transplant

-Skin irritations near the treated area (rashes, sunburn, acne, etc.)

-Sick (cold, flu, etc.)

-Had Botox in the past 2 months

-Used Accutane in the past year

For any additional questions or concerns please call or message us!

Gloss Nail Spa