Permanent Makeup & Microneedling Consent Permanent Makeup & Microneedling Consent Form Salon Lamont Client Information Full Name * Date of Birth * Phone Number * Email * Emergency Contact (name & phone) I confirm that I am 18 years of age or older. * Services Requested Permanent Makeup Eyebrows (microblading / powder) Eyeliner Lip color / lip blush Microneedling Face Neck / décolleté Under-eye Scalp Treatment area(s), desired result, and any notes If permanent makeup and microneedling are both booked, I understand the stylist will schedule them apart as needed for healing. Permanent makeup and microneedling should not be done on the same area during the same session. Health & Medical History Please check all that apply: Pregnant, possibly pregnant, or breastfeeding Taking blood thinners (e.g., warfarin, Plavix, or regular aspirin/NSAID use) Bleeding or clotting disorder Diabetes Autoimmune disorder or immune-suppressing medication History of keloids or raised/hypertrophic scarring History of cold sores (herpes simplex) in the treatment area Active acne, rosacea, eczema, psoriasis, or dermatitis in the treatment area Isotretinoin (Accutane) within the past 12 months Botox, filler, chemical peel, laser, or microdermabrasion in the treatment area within the past 4 weeks Sunburn, open wounds, or active skin infection in the treatment area Seizure disorder, pacemaker, or other implanted medical device Hepatitis or other bloodborne illness Allergy to lidocaine or other numbing products, pigments, or metals Existing tattoos or cosmetic tattoos in the treatment area Other (please explain): Current medications and supplements If any of the above apply, please consult your physician before treatment. The artist may decline or postpone any service. Acknowledgment of Risks & Results: Permanent Makeup I understand that: Permanent cosmetics are implanted pigment. Color will look darker and sharper at first and will soften as it heals, usually over 4 to 6 weeks. Pigment may fade, shift in tone, or change over time, especially lip color. Results vary with skin type, skin care, sun exposure, and individual healing. One session is often not enough. Touch-up appointments are usually needed and may be billed separately per the salon's policy. Some asymmetry is natural. Perfect symmetry cannot be guaranteed. Permanent cosmetics are considered permanent. Complete removal is not guaranteed and may require laser or other procedures. Risks include redness, swelling, tenderness, scabbing, infection, allergic reaction to pigment or numbing agents, scarring, and uneven healing. I have read and understand the permanent makeup risks and results above (required only if permanent makeup is selected). Acknowledgment of Risks & Results: Microneedling I understand that: Redness, swelling, tenderness, pinpoint bleeding, dryness, and flaking are normal for about 24 to 72 hours. Bruising may occur. Temporary sensitivity or hyperpigmentation may occur, especially with sun exposure. Microneedling can trigger a cold sore outbreak in people with a history of herpes simplex. Pre-treatment medication may be recommended. Multiple sessions, usually spaced 4 to 6 weeks apart, are needed for best results. Results are not guaranteed. Risks include infection, scarring, and rare adverse reactions. I have read and understand the microneedling risks and results above (required only if microneedling is selected). Aftercare I agree to follow the aftercare instructions I receive, including sun protection, avoiding picking or peeling, avoiding saunas, swimming, and heavy sweating for the time advised, and avoiding retinoids and exfoliating acids on the treated area until cleared. I understand that not following aftercare may affect healing and results. I agree to follow aftercare instructions. * Photos (Optional) I consent to before and after photos being taken for my client record. I consent to my photos being used by the salon for portfolio or social media. My face or identifying features will only be shown if I agree. Client Consent & Signature I certify that the information I have provided is accurate and complete. I have disclosed all relevant medical conditions and medications. I have had the opportunity to ask questions, and I understand the risks, expected results, and aftercare. I consent to the services I checked above. I have read and agree to the statements above. * Client Signature * Sign above using your mouse or fingerClear Printed Name * Date * Artist Artist Name Date Artist Signature OptionalClear Artist Notes (pigment / products used, needle configuration, depth, aftercare given) Sign & Submit Consent
