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Microblading by Joanna Consent Form for Micropigmentation and/or Permanent Makeup

Name(Required)
Address(Required)

Consent

Consent(Required)
I certify that I am over the age of 18, I am not under the influence of drugs or alcohol, I am not pregnant or nursing, and I consent to receiving the indicated micropigmentation or permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.
Consent(Required)
I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. Corneal abrasions are a rare side effect, especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the permanent skin pigmentation procedure/s, and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure/s.
Consent(Required)
There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to the pigment. I understand that if I have any skin treatments, 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.
link text
Consent(Required)
I have received pre- and post-procedure instructions and read them online on the Microblading by Joanna website and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician. If I have ever had cold sores, I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.

Here is link to read the pre- and post-procedure instructions instructions
Consent(Required)
I understand that before and after photographs of the said procedure/s are conditions of such procedure/s. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. I accept full responsibility for the decision to have this cosmetic tattoo work done and understand that there is a no refund policy. I understand that the cost of touch-up’s are not included in the procedure and the cost of touch up’s differs as time lapses from the original date procedure was dine.

Medical History

In order to provide you with the most appropriate treatment, please complete the following questionnaire. All of the information is strictly confidential and not shared with any third parties.
Are you currently under the care of a physician?(Required)
Do you have any of the following medical conditions/problems?(Required)
(please check the boxes that applies to you)
Have you ever had an allergic reaction to any of the following?(Required)
(please check the boxes that applies to you)
Please list:
Please list:
Please list:
Please list:
Have you recently had treatments such as facials, peels, microdermabrasion, etc. on your face?(Required)
Do you form thick or raised-scars from cuts or burns?(Required)
Do you get Hyper-pigmentation (darkening of the skin), Hypo-pigmentation (lightening of the skin) or marks after physical trauma?(Required)
Which of the following best describes your skin type?(Required)
Have you had any recent tanning or sun exposure that changed the color of your facial skin?(Required)
Gender(Required)
Are you pregnant or trying to become pregnant?(Required)
Are you breastfeeding?(Required)
Are you using contraception?(Required)
Consent - Medical(Required)
• I certify that the preceding medical, personal, and skin history statements are true and correct.
• I am aware that it is my responsibility to inform the technician, of my current medical or health conditions and to update this history.
• A current medical history is essential for the permanent makeup technician to execute the appropriate treatment procedure

Permanent Makeup Cancellation & No-Show Policies

service will be allowed Permanent makeup is all about you! We want to provide you with the highest standards of service and personal care, in the most professional environment so that you will return and recommend our services. 

  

 

Appointments:  

To schedule any Permanent Cosmetic Appointment, we require a $100 None-Refundable Deposit Fee for securing your spot for appointment. This deposit needs to be paid at the time of booking.  

 

 

Initial Consultation: 
$50 None-Refundable Consultation Fee is required at the time of booking.  The $50 will be credited to your procedure cost.  If you cancel/reschedule your appointment less than 48 hours’ notice you will lose the $50 and require a new deposit to be paid before rescheduling your next appointment. 

 

Cancellation – If you have an appointment, this time is reserved exclusively for you. If you must cancel your appointment, we require a 48-hour cancellation notice in advance for services.


Rescheduling: 

If you need to reschedule an existing appointment, please give us 48 hours’ notice and we will carry your deposit over to the new appointment this can. Only be moved ONE time only please, any rescheduling after you will lose your deposit. We encourage you to contact us directly by phone or by text when needing to cancel or reschedule your appointment.

 

Emergency:

If you have a medical emergency and must cancel with less than 48 hours' notice, please provide your medical receipt and your appointment can be rescheduled for another time with no additional deposit required. 

 

No Show Policy: 

Any client that DOES NOT SHOW for a scheduled appointment will forfeit their $100 deposit and will be required to pay for any future appointment in full.

 

Late Arrival:

Arriving more than 30 minutes after, you will have to be rescheduled and we will move your deposit ONE time only. This is as a curtesy to the following guest since we can’t extend their time.

 

Please be mindful when you do not cancel or reschedule your appointment in a timely manner, it affects three parties: you, the technician, and other clients. Thank you for your cooperation. We look forward to your visit.

 

No Other Guests:

Due to liability reasons no other guests or children are allowed in the salon’s treatment area. We want to provide the best relaxation atmosphere for clients only. Thank you for your understanding.

 

Cell Phones: 

Cell phone use is not permitted while permanent makeup services are rendered.  

 

Permanent Makeup Done by Another Technician:

Recoloring permanent makeup done previously by anyone else is not “just a touch-up” since it is not the original work of our provider. Therefore, fees start at the new permanent makeup prices. Two or more appointments may be necessary to achieve and complete most permanent makeup correction procedures.  Note: Permanent Makeup Maintenance / TOUCH-UP – Touch-up’s are not included in the original procedure fee.  

 

Pricing: All prices quoted are subject to change without notice. All purchases and services are final, and there are NO refunds.  

 

Remaining Balance is due on the day of your procedure via cash, check, Zelle or Venmo.  

 

Venmo Contact: 773.396.0620

Zelle Contact: 773.396.0620

 

Additional Treatment Policy

1.     We reserve the right to refuse services to anyone. 

2.     Two or more appointments may be necessary to achieve and complete most permanent makeup procedures depending on each person’s skin. Touch-up fees will apply. 

3.     Since scar tissue is abnormal, multiple sessions are usually needed to achieve satisfactory results with medical grade tattooing/camouflage. 

4.     Only clients receiving within the treatment room.

 

Consent - Permanent Makeup Cancellation & No-Show Policies(Required)

Request and Consent to Photography and/or Video Record

Request and Consent to Photography and/or Video Record
Your aesthetician may need to photograph and/or record you to document a medical condition, help with diagnosis and/or treatment of a condition, and/or to help plan the details of a treatment. Photographs and/or recordings taken for these clinical reasons do not require your written permission. Your aesthetician does need your written permission to use your photographs and/or recordings for the non-clinical reasons below. I hereby authorize Microblading by Joanna, including the attending aesthetician or other designated person(s), to photograph and/or video me for the following purposes: 1. To show or release to current or future Microblading by Joanna patients on company website for the purpose of education and consultation. I understand these photos or videos can be taken at any time during my treatment which includes pre-treatment, post-treatment, pre-operative, intra-operative, post-operative photos, and/or videos of my treatment.
Consent - Photography and/or Video Record(Required)
I hereby certify that all of the information provided by me in this application is correct, accurate and complete to the best of my knowledge.
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