Medical Aesthetics Release Form

PROCEDURE CONSENT

Evolour Microblading and PMU
Medical Aesthetics Release Form.

Complete the release form before microblading and permanent makeup services.

Review pre-procedure and after care information below

Check your email for updates and more post treatment information.

EVOLUER RELEASE FORM

FIRST NAME

LAST NAME

PHONE NUMBER

BEST EMAIL

Evoluer Procedure Permission

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure / treatment and accept the risks.

I agree that, although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications of this treatment. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

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

The healing process requires commitment from the client to follow healing protocols and stay away from regiments that could interfere with obtaining the desired appearance. I understand that to achieve the best result I must be willing to follow the healing guidelines given to me. Touch up sessions for procedures should be scheduled 8 weeks from the first session. I understand that touch ups will not be scheduled within the 8 week required healing time. I understand that I may experience scabbing, flaking, and changes in color during the healing time. This is the normal part of the healing process and I should not try to pick scabs or cover up with personal regiment. I understand that applying makeup to the treated area will cause the healed result to be less than desirable or possible infection and acknowledge that I have been advised against using these products during healing. I understand that if I decide to have a facial, laser treatment or any other services immediately after or during the healing process that the results may not be best. I understand that if I go out into the sun, pool and/or beach that there will be a significant amount of fading. I understand that I should refrain from sweat producing activities as they too may hinder results or cause infection.

I understand that I am a model client for this procedure and that my technician is either learning or new to the procedure I am about to undergo. I accept their level of experience and understand the risks of receiving a procedure as an educational opportunity for my technician. I have had proper home care treatment for my procedure explained to me. I understand that these procedures may produce some swelling, redness, itching, discomfort, numbness and adverse side effects. *I understand that the treatment I have chosen is for cosmetic purposes only and NO GUARANTEES have been made to me concerning the results of the procedure. *I understand that the results achieved and number of treatments required will differ from person to person. I can confirm that all of the information provided by me is correct and truthful. I have accepted this service at either discount or for free and understand that there are no refunds and that this special pricing is only given due to the nature of this procedure, additional fees may apply for future procedures and or services.

For the purpose of documentation, advertising, record and use in portfolio, I CONSENT to the taking of “before”and“after” photographs of my procedure.

Procedure Care Instructions

Procedure Information and Aftercare:

We only use the very finest pigments available. Some procedures may need to be repeated because the original application can fade anywhere from 25% to 40%. Individual chemical and genetic makeup can affect the final result.

We Cannot Predict Your Fading Experience
It is fully possible to get the perfect results with only one application; however, this cannot be guaranteed. Please remember that the amount of pigment you retain or lose after your initial application is not a reflection of the quality of work. Pigment retention varies with each person. In case your procedure must be repeated, you will need to wait at least 21 days of the date of your original application.

Application Cannot Be Repeated Within 21 Days or Less
The tissue is not ready to absorb new pigment although your skin looks healed. Please be patient.
We Charge an Additional Fee for Touch Ups
Most touch-ups can be done in 30 to 45 minutes.

Pre-Care Instructions:

Do not work out 24 hours before the procedure.
NO alcohol or caffeine 24 hours before the procedure (Yes, there is caffeine in decaf
coffee and tea!).
Avoid sun and tanning one week prior to the procedure.
Do not take Aspirin, Niacin, Vitamin E or Advil/Ibuprofen 24 hours before the procedure.
Avoid power shakes and power greens, Fish Oil, and "Hair, Skin, Nail" supplements 24
hours prior to procedure.
Discontinue Glycolics, Chemical Peels and Retin-A 4 weeks prior.
Refrain from use of any Alpha Hydroxy Acid (AHA) products close to the eyebrow area
2 weeks prior to and 2 weeks after your procedure. Check your moisturizer, face wash
BB or CC creams and makeup primers for anything that says acid.
No waxing body hair or tinting if doing brows for one week before the procedure.
1. Please Note: Female clients will be more sensitive during their menstrual cycle as well.
You have to be off any kind of Accutane for 1 year. NO Exceptions!
No Latisse (on lashes or brows) for a minimum of three weeks prior to permanent
eyeliner or brow.
For permanent eyeliner, eyelash extensions must be removed 3-5 day prior.
Fillers should be done six weeks prior to scheduled procedure or six weeks after
procedure.
Botox should be performed two weeks prior to scheduled procedure or two weeks after.

Aftercare Daily Regime:

Cool showers are recommended, DO NOT saturate the treated area, it is best to perform
after care as a separate regime from your shower so that the area can be kept dry, over
saturating will cause softening of any scabs and may pull out pigment.
Before showering lightly cover treated are with ointment to help repel water, pat dry
gently after
Gently wash the treated area twice a day or as needed and gently pat dry as to not disturb
healing, apply a very thin layer of ointment, DO NOT over saturate the procedure with
ointment, only a thin layer is needed.
Do not touch the treated area unless applying ointment or washing with antibacterial
soap. No scratching, rubbing, or picking of the treated area
Be cautious around the area (such as pulling clothing over your head)
Do not apply makeup on treated area until healed
Apply ointment 1 - 3 times a day on the treated area until peeling comes off; normally 5
to 7 days. (Again do not peel the area yourself, let this fall off naturally)
Follow with antibiotic ointment for one week
Touch up may be done after 21 days, however its best to wait 30-45 days

I have read the EVOLUER RELEASE FORM Procedure Care Instructions and understand the above information and of my own free will I choose to move forward with my procedure.

I have read and understand the post-treatment home care instructions and will check my email for further instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the practitioner immediately.

I certify that I have read and fully understand the above consent and procedure permit; that the explanations therein referred to were made and accept full responsibility for these and or other complications, which may arise or result during or following the procedure. The treatment is performed at my request according to this consent, pre-procedure form and post procedure guidelines. I hereby authorize the technician to perform the procedure on me as a model client and release my technician from possible liabilities resulting from experience level.

All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment), whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this aesthetic tattoo and skin care treatment / procedure, which may be affected by the treatment / procedure performed today. I also release Evoluer Microblading and PMU of any liability that may arise from this procedure / treatment.

Your Signature

Check your email / spam / junk folders for more information and a confirmation email.

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ABOUT US

evoluermicroblading.com

Evoluer Microblading and PMU

15560 King Rd. Riverview, Michigan 48193

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