Microblading | Rammy Rose

Microblading: Online Consent Form

Please fill out the following form.

First name

Last name

Email

Phone

Date of birth

Year

Month

Day

Please circle all current and prevoius medical conditions listed below that apply to you

Are you being treated for any other conditions not listed above?

Yes

No

Are you currently using Retinol Cream or Accutane?

Yes

No

Are you currently using any products that contain AHA's or Gycolic Acids?

Yes

No

Have you had any facial tattoos or piercing?

Yes

No

Have you had any Botox or fillers within the last 6 months?

Yes

No

Have you had any Tanning services within the last 2 months?

Yes

No

Have you had any severe facial sun burns within the last year?

Yes

No

Please check the box after acknowledging each statement

The Microblading procedure carries with it known and unkown complications and consequenced associated with minor invasive skin treatements including, nut not limited to infection, scarring, inconsistent colour, pigment migration, fanning and fading. The actual color of the pigment might be modified slightly, due to the tone and color of skin. Therefire, the process is not of exact science but an art

Any skin treatments, laser hair removal, plastic surgery, botox, fillers or other skin altering procedures may result in adverse changes to my permnanent cosmetics. Some of these potential adverse changes may not be correctible

Taking of before and after photographs of the said procedure is a condition of the procedure

The pre and post instructions with the care kit have been provided to ensure the microblading procedure is effective and long-lasting. It is the client's reponsibility to strcitly adhere to them. Failure to do so will jeopardize the chances for a successful procedure

The treatment fees have been discussed with me and I understand them. We require 24 hours notice if cancellations or 50% treatment cost will be charged

THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS, READ IT CAREFULLY

I confirm the answers I have given in this form are correct, and I have not withheld any information requested by this form
I have been informed of the proper use of equipment for the services I am receiving
I have been advised of all risks associated with the use of equipment required for the services I am receiving. I have been advised of all risks associated with the services and procedures I will be receiving. I agree to comply with all instructions provided by the operator
I hereby release Rammy Rose Hair & Beauty ltd its affiliates, officers, directors, agents, employees and contractors from liability for any injury, loss or damage that may result from my use of equipment or from any services provided or treatment rendered. This release binds my heirs, successors and assigns.

Signature

Date picker

I declare that the info I’ve provided is accurate and complete.

Please show your filled form to the service provider, without their acknowledgement, this form cannot be submitted, and we will not start the service until the form is submitted

Service Provider Signature

I have checked the client’s form for any contraindications and have consulted with the client what the effects of these contraindications will have during and after the service