Treat Yourself Please complete and submit all consent forms before booking your appointment. Treat Yourself All consent forms must be completed and submitted prior to booking your appointment. PMU Consent and Release Form "*" indicates required fields Step 1 of 3 33% Have you read the FAQ page on the website regarding your desired service?* Yes, I have read the entire FAQ page, and am ready to book my appointment. No, I have not read the Lips FAQ page and/or PMU Brows FAQ page. Please read the FAQ page that refers to the service you are booking, and then return to the booking page to complete your Consent and Release Form. Lip Tinting FAQ Microblading FAQ • Infection Although very rare, there is a risk of infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See After Care sheet for instructions on care. • Uneven Pigmentation This can result from poor healing, 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. Adjustments may be needed during the follow up session to correct unevenness. • Excessive Bruising or Swelling Some people bruise and swell more than others. The bruising and swelling typically disappear within 1 ‐ 5 days. Most people don’t bruise or swell at all. • Anesthesia Topical anesthetics are used to numb the area being treated. Lidocaine, Prilocaine, Benzocaine, Tetracaine and Epinephrine in a cream or gel form are typically used. If you are allergic to any of these please inform us now. • 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 technician of any tattoos or permanent cosmetics. I have read and understand all risks and hazards.* Yes No Allergic Reaction*There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5‐7 day patch test to determine this. Please indicate your choice below to waive or take the 5-7 day patch test. Waive Take Please read carefully, and check the box next to the statement that is true.*We REQUIRE all clients undergoing Lip Blushing, (that have had cold sores before), to use an Antiviral medication such as VALTREX pre and post procedure, (5 days before and 5 days after). Cold sores are a common reaction post Lip Blushing if you’ve had them before. I have not had any cold sores/fever blisters before. I have had cold sores/fever blisters before and will take Valtrex as required. Photograph Release Consent*Bella Aesthetics Med Spa would like to take before and after photographs depicting the results of your procedure. We would also like your permission to use these photographs for advertising. Advertising may include portfolios, brochures, online or print advertisements, etc. Please check “YES” or “NO” below to indicate whether you consent to our use of your photographs for advertising purposes. YES, feel free to use photographs of me. NO, please do not use photographs of me. Please read carefully, and check the box next to each statement that it is true.* I will not drink caffeine or alcohol for 24 hours prior to my procedure. I will not be under the influence of drugs for 24 hours prior to my procedure. I am not pregnant or breast feeding. I have not nor will I use skincare products containing Retin A/Retinol 7 days prior to my procedure. I do not currently nor have I taken Accutane within the last 12 months. I have not had Botox and/or any other cosmetic filler procedures within the past 2 weeks prior to my procedure. I will not take Vitamin E, Aspirin, Niacin, Fish oil supplements, Advil, Ibuprofen or any blood thinning medication 72 hours prior to my procedure. I have read and understand all aftercare instructions. I have reviewed the FAQ prior to my appointment and I understand the information listed there. I understand that a certain amount of discomfort is associated with this procedure and that redness, bruising or swelling may occur. I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color. I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup. I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure performed. I understand that implanted pigment color can change or fade over time due to circumstances beyond the technician’s control and I will need to maintain the color with future applications and a touch‐up session within 4‐12 weeks. I do not and will not have dry or chapped lips prior to my Lip Blushing appointment. I will not have any lip fillers or Botox in the lips for 6-8 weeks prior to my appointment. I acknowledge that any permanent makeup procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper‐pigmentation. If the statements above are questionable, please explain below. Or, you may get a Dr’s note allowing you to proceed with the procedure. If you choose to get a Dr.'s note, please indicate so below, and bring the note with you to your appointment.*What would you like to improve about your eyebrows and/or lips? (Shape, Color, Density, Thickness…)This field is hidden when viewing the formIf you are booking a touch up, please upload a current picture of your eyebrows or lips.Pictures must be less than 300MB in size total. You may upload jpg, png, gif, or pdf files. If your picture will not upload to this form, please email your picture to lindsey@thebellaglo.com. In the subject line, please include your name. Drop files here or Select files Max. file size: 300 MB. If you are booking a touch up, please upload a current picture of your eyebrows or lips.Pictures must be less than 300MB in size total. You may upload jpg, png, gif, or pdf files. If your picture will not upload to this form, please email your picture to lindsey@thebellaglo.com. In the subject line, please include your name.Max. file size: 500 MB.Please upload a picture of your ID to verify that you are over 18 years of age.*Max. file size: 500 MB.ConsentI acknowledge that I am at least 18 years of age and 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. I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Bella Aesthetics Med Spa to perform the Microblading procedure on me. I hereby release Bella Aesthetics Med Spa from any liability arising from the risks that are known and/or inherent in the Microblading procedure. I agree.Today's date* MM slash DD slash YYYY Name*Please type your name below. First Last Phone Number*Email Address* Referred ByEmailThis field is for validation purposes and should be left unchanged.
