General Consent & Procedure Permit Form

Please Read Completely & sign at the bottom

If any unforeseen condition arises in the course of the microblading procedure, I authorize my technician to use her professional judgement in deciding upon what action she feels is necessary in the given circumstances.

I accept the responsibility for determining and agreeing to the color, shape and position of the microblading, lip, or eyeliner procedure as agreed upon during the consultation.

I understand that an allergy test does not guarantee that I will not develop an allergic reaction to the pigment or the anesthesia.

I fully understand and accept that non-toxic pigments are used during the procedure and that the results may fade away over a period of 1-3 years.  Even once the color fades, some trace pigment may stay in the skin indefinitely.

I have been informed that the highest standards of hygiene are met before, during and after the procedure, and that sterile and/or disposable tools and pigment containers are used for each individual client, procedure and visit.

I understand and accept that each procedure is a process that may require multiple applications of pigment to achieve desired results, and that 100% success cannot be guaranteed from the first procedure, and that I may have to return for a repeated procedure to achieve my desired results.

The results of any microblading, lip, or eyeliner procedure is determined by the following factors:  medication, skin types/characteristics (dry, oily, sun damaged, thick, thin), Ethnicity, Personal PH Balance, Alcohol intake, smoking, medical conditions (known and unknown), and post-procedure after care.

Upon completion of the procedure there may be some swelling and redness of the skin, which will subside in 1-4 days.  IN some cases bruising may occur.  I may resume normal activities following the procedure; however, using cosmetics, excessive perspiration, and sun exposure should be limited until the skin has fully healed.  I know to refer to the aftercare sheet for more details.

I understand that the procedure results should look acceptable enough for me to appear in public without additional makeup on the affected area.

I have been advised that the true color will be seen 1 month after each procedure, and that the pigment may vary according to skin tones, skin type, ethnicity, age and condition.  I understand that some skin types accept pigment more readily, and no guarantee on exact color results can be given.

To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my wellbeing as a direct or indirect result of my decision to have the microblading, lip, or eyeliner procedure performed at this time.

I agree to follow all pre and post procedure instructions provided and explained to me by the technician.  I can confirm that I received a copy of the aftercare instructions.

Being of sound mind and body, I hereby release the technician Julie Golba, from any and all responsibility.  I fully accept any and all responsibility myself for any consequences that might stem from my decision to have microblading, lip, eyeliner, or any other permanent or semi-permanent cosmetics procedure performed by Julie Golba.

For the purpose of documentation, record, and use in portfolio, I also consent to the taking of “before” and/or “after” photographs of my procedure, and any future procedures.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THE EXPLANATIONS THEREIN REFERRED TO WERE MADE CLEAR, AND I ACCEPT FULL RESPONSIBILITY FOR ANY COMPLICATIONS WHICH MAY ARISE OR RESULT FROM, DURING, OR FOLLOWING THE MICROBLADING, LIP, OR EYELINER PROCEDURE, AND ANY FUTURE PROCEDURES.  THE TREATMENT IS PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT, PRE-PROCEDURE FORM, AND POST PROCEDURE GUIDELINES.

I HEREBY AUTHORIZE TECHNICIAN JULIE GOLBA TO PERFORM MICROBLADING, LIP, OR EYELINER PROCEDURE ON ME AT THE LOCATION LISTED BELOW, ON THIS DATE AND ANY OTHER DATES ALSO LISTED AND INITIALED BY ME ON THIS FORM.

Client Signature

TECHNICIAN:  SO REAL SKIN 7300 SECOR RD. #9, LAMBERTVILLE, MI  48144  (419)290-0055

ADDITIONAL PROCEDURE DATES – Client must initial for updated consent every time. 

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