Microblading  ‐ Consent and Release

This form provides information about microblading, which involves the application of semi‐permanent makeup.  You are
encouraged to carefully review the information provided in order to make an informed decision as to whether to undergo
the microblading procedure.
Microblading involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing.  Initially the color
will appear more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40‐50%, soften and
look more natural. The pigment is semi‐permanent and will fade over time and will likely need to be touched up within 12
to 18 months.
All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross
contamination guidelines are carefully adhered to.
Generally, the results of microblading are excellent. However, a perfect result is not a realistic expectation. It is usual to
expect a touch‐up after the healing is completed.
Possible risks, hazards or complications:
• Pain: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work
better on some people than others.
• Infection: Although rare, there is a risk of infection. The areas treated must be kept clean and 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.  Adjustments may be
needed during the follow up session to correct unevenness.
• Excessive Swelling or Bruising: Some people bruise and swell more than others. Ice packs may help and the
bruising and swelling typically disappears within 1‐5 days. Some people don’t bruise or swell at all.
• 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 us now.
• Allergic Reaction: There is a possibility of an allergic reaction to the pigments or other materials used. You may
take a 5‐7 day patch test to determine this. Please initial to: Waive____ or Take______.
The alternative to these possibilities is to use cosmetics and not undergo the microblading procedure.
Consent for Microblading Procedure:   Please read and initial all lines.

______ I am currently not under the influence of any drugs or alcohol.
______   I am not pregnant.
______   I do not currently nor have I taken Accutane within the last 12 months.
______   I have not had Botox and/or other cosmetic filler procedures within the past two weeks.
______   I have not had surgery of any kind within the past six months.
______   I have not taken any blood thinning medication with the past 72 hours nor have I taken aspirin within the past 24
______  Aftercare instructions have been explained to me and are attached to this consent form.  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 my technician.

I have reviewed the Eyebrow Microblading FAQ on www.genejuarez.com prior to my appointment, and I
understand the information listed there.
______ I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and
bruising may occur.
______ I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They
will alter the color.
______ I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent
______ I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any
procedure done today.
______ I understand that implanted pigment color can change or fade over time due to circumstances beyond the salon’s
control and I will need to maintain the color with future applications and a touch‐up session within 8‐12 weeks.
______ I acknowledge that the microblading procedure involves inherent risks and that there is a possibility of one or
more complications during and/or following the procedures such as: infection, misplaced pigment, poor color
retention and hyper‐pigmentation.
______ I have been quoted the cost of today’s appointment which includes one (1) touch‐up within 8‐12 weeks following
today’s appointment. After 12 weeks, a fee will apply for any further touch‐ups. There will be no refunds for this
elective procedure.

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