Statement of Consent and Recitals: Please read and initial all lines
_____Aftercare instructions have been explained to me and a written copy has been 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 text you.
_____I understand that 70% of the healing is up to me in the 1st day. I MUST wipe with the water soaked wipes provided and clean hands every hour on the hour followed by ointment. The 2nd day the same and after that morning and night.
_____I understand if I decide to go against the provided instructions of aftercare and use other ointments or products, that WILL result in extra costs as the pigment will not retain as desired.
_____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, Renovo, Alpha Hydroxyl and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.
_____I understand the healing process takes approximately 30 days. The brows will appear darker at first and then heal softer. I will experience changes until they are healed 4-6 weeks after the 2nd session.
_____In some occasions, a 3rd session may be needed due to improper after care, improper preparation, which are out of TP control, even simply every skin healing differently, which may result in extra cost to me.
_____I understand that tanning beds, pools, sun exposure, spicy foods, smoking, some skin care products and medications can affect my permanent makeup.
_____I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue and differences in thicknesses of skin.
_____I will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I am scheduled for an MRI.
_____I accept the responsibility to explain to you any desire for specific colors, shape, and position for my procedure done today.
_____ I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond our control. I will need to maintain the color with future applications on average once a year and a touch-up session is mandatory between 4-6 weeks of the initial session.
_____I acknowledge that the proposed procedures(s) involve risks inherent in the procedure, and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
_____I have been advised that a touch-up session is mandatory to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. This touchup must be completed between 4- 6 weeks of initial procedure. If I opt out from this contract, to follow through with the touch up session, I acknowledge I WILL be charged by TP a session fee of $250 either way and agree for it to be charged onto the credit card I have provided on file.
_____I have been quoted the cost of today’s appointment, and the cost of the touch-up. Touch-ups must be completed between 4-6 weeks of initial procedure to be considered a touch-up price. Anything after that time frame may result in an additional charge.
_____ I acknowledge that I will agree to the drawn design by my tech before the blading session begins. Once the blading starts, there may not be a chance to change the design.
_____There is no guarantee, even if a patch test is given, that I may not have an allergic reaction.
_____I WILL NOT apply too much ointment knowing that it can pull out the pigment and can also suffocate the skin and create infection.
_____Please keep in mind you sought me out for either my reputation or you have been referred by a friend. So, if in a rare occasion you are not satisfied with your results, please remember this is a process of many steps. Allow me to finish all the steps before drawing your conclusion of the service. If there are any complaints, this will violate this contract and be considered slander if not given the change to correct any issues that may arise, especially before the perfecting session.
_____I am happy with the choice I made to come to Totally Polished and EXCITED FOR MY NEW BROWS!
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). I have had the opportunity to ask questions, and all my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize Jessica Hartman DBA Totally Polished, as my Eyebrow Microblading Technician to perform on my body the microblading procedure desired today.
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 on others.
Infection: Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the areas. You must treat them as the wounds they are.
Uneven Pigmentation: This can result from poor healing, poor after care, 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 please remember, I am human, nothing is perfect. So, adjustments will be needed during the follow-up session to correct any unevenness.
Excessive Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Most people don’t bruise or swell at all.
Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid may be used. If you are allergic to any of these, please inform me NOW, before the beginning of the service.
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 MRI Technician of any tattoos or permanent cosmetics.
The alternative to these possibilities is to use traditional cosmetic and NOT undergo the Semi-Permanent Eyebrow procedure.
Consent and release for procedures performed:
Consent and Release Agreement
This form is designed to give information needed to make an informed choice of whether to undergo the microblading application. If you have any questions, please don’t hesitate to ask.
Although microblading is effective in most cases, no guarantee can be made that a specific client will benefit from the procedure.
This is the process of targeting the basal layer of the epidermis and inserting pigment. Because of this, it is a form of tattooing, though only semi-permanent.
All instruments that enter the skin or come in contact with body fluids are disposable, and disposed of after use. Cross contamination guidelines are strictly adhered to via the State of Ohio Body Art regulations.
Generally, the results are excellent. However, a perfect result is not a realistic expectation. It is a mandatory 2 step process and requires a touch-up after healing is complete in 4-6 weeks after the initial session.
Initially the color will appear more vibrant or darker compared to the end result. Usually within 5-7 days the color will fade 40-50%, soften, and look more natural. The pigment is semi-permanent and will fade over time. Additional touch-ups are needed within 6 months to 2 years in order to maintain the brow.
A touch up is only considered a touch up, and at touch up pricing, IF the brow design is still present and will not need to be redrawn per TP. If you schedule a touch up but more work is needed, the price will be adjusted and or may need to be rescheduled in additional to any charges that may apply.
Photography Release Consent
We would like your permission to use these photos and/or videos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.
Yes, feel free to use them No, please do not use them
Client Medical History Form
Do you have or previously had any of the following: (Cirlce YES or No)
YES NO caffeine with in the past 24 hours
YES NO alcohol within the past 24 hours
YES NO body / facial tattoos
YES NO steroids
YES NO can you take over the counter anti histamine
YES NO Retin-A or Hydroxyl Glycolic Acid past year
YES NO heart conditions
YES NO cold sores, blisters, canker sores
YES NO bruises easily
YES NO HIV positive
YES NO easily swells
YES NO herpes
YES NO history of MRSA
YES NO Botox (last treatment______________________________)
YES NO diabetes
YES NO hepatitis A B C D
YES NO forehead/brow lift
YES NO easy bleeding
YES NO facelift
YES NO alcoholism
YES NO abnormal Heart Condition
YES NO take medication before dental work
YES NO chemical Peel (Last Treatment_______________________)
YES NO pregnant now – Breastfeeding now
YES NO brow or Lash Tinting
YES NO autoimmune disorder
YES NO oily skin (how oily 1-5, 5 being super oily_________)
YES NO cancer (Year______________)
YES NO Accutane or acne treatment
YES NO chemotherapy/ radiation
YES NO tan by sun or tanning salon
YES NO tumors/ growth/ cysts
YES NO difficulty numbing with dental work
YES NO aspirin, Ibuprofen, etc.
YES NO taking blood thinners such as: Coumadin etc.
YES NO allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl Alcohol, Carbopol, Lecithin, Propylene Glycol, Vitamin E Acetate, etc.______________________________
YES NO allergies to metals, ____________________________________
YES NO any diseases or disorders not listed_____________________________________________
YES NO do you use skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl?
Please list any medications you are taking_________________________________________________
I agree that all the above information is true and accurate to the best of my knowledge
Credit Card Consent and Policies
Date________________________________________________ Birth date_____________________________________
Address___________________________________________________________________________ Zip _____________
Current Credit Card #_________________________ Exp. Date____________ 3-digit code ______________
_______ We refuse to provide any service that cannot be performed safely and reserve the right to refuse any service that may require medical attention. Prices, services, or details of the appt. are subject to change without notice.
The cancellation policy of TP, by which I will abide, is as follows… Reservation must be cancelled 24 hours prior to appointment or full price of service will be charged. If issued a gift certificate, it may become void to cover the cost of missed appointment. Deposit on credit card on file will be charged. Late arrivals may result in an adjusted, full price service ending at the regularly scheduled time
I authorize Totally Polished to charge my credit card, that I provide on this file, in accordance to TP cancellation policy, to fulfill my commitment of my scheduled appointment, hence forth, without further notice. I acknowledge that it is my responsibility to ensure that the most accurate contact information, including but not limited to, credit card information, cell phone number and best email, are provided and always up to date. If in the rare occasion, TP needs to charge my card and the info is out of date, I acknowledge I will be responsible for any further costs, not limited to bank or legal costs, to secure original charge.
It is my responsibility to ensure that my appt. is properly scheduled, as requested, which entails, making sure I receive my reminder, reading it thoroughly, confirming the time and date, and accepting the reminder by following the prompts that are provided. If the appt. reminder has a different time or date as requested, it is up to me to reach out to TP and ask for the original requested appt. By confirming the appointment, I agree to be charged for the service time. If I do not confirm my appt. I am still responsible for the time however, if TP feels they can fill the time slot with a more committed appt. I will be subject to lose my selected appt. time slot without any notice on TP behave. I acknowledge to ensure the best service from TP that this is why they provide the online scheduler and automatic reminder system.
I acknowledge that all services provided by TP are non-refundable along with any deposits.
I have discussed all personal information, allergies, medical history, medications, and concerns that I may have in its entirety with my technician before the procedure, and understand there are NO refunds otherwise decided by TP.
In the rare case that I am not satisfied with my enhancement provided by Totally Polished, I agree to first contact my technician regarding this issue. I agree not to publicly defame Totally Polished or its technicians on any online or social media network IE. Facebook, Google, Instagram, Pinterest, Twitter, or Yelp. Doing so is prohibited and I understand TP will seek legal action against my claim to dispute it and that I will be responsible for any fees associated in doing so.
I hereby grant to Totally Polished the full right to take, publish, and reproduce photographs of me, my face, my eyes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the rights to retouch these photographs as deemed necessary by Professional or Totally Polished.
I agree to follow the care and maintenance instructions provided by Totally Polished and/or Professional for the use and care of my procedure. I understand by not following the instructions 100% THAT I RISK INFECTION, LOSS OF PRODUCT OR RETNETION, 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.
I agree that all the above information is true and accurate to the best of my knowledge