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Microblading Client Record - Katelyn McCloy


Last Name:

Beth

First Name:

Kidwell

Address:

836 Morrison St

City: 

Fremont
 

State:

Oh
 

Zip: 

43429
 

Date of Birth:

And your technician;

Full name: Katelyn McCloy

Salon Address: 1700 River Street Fremont, OH 43420

Phone number: 419-559-7123

I am obligated to perform procedures in strict compliance with all hygiene & health protection measures. The following information is confidential and shall also be handled in that way. In order for me to perform the eyebrow tattoo procedure in a safe manner, please answer the following health questions truthfully. I assume no liability in case of false information.

Do you suffer from any of the following?

 

Are you taking any medication for blood thinning?

Do you have a problem with wounds healing?

Have you undergone surgery in the last 14 days?

Have you been exposed to radiation or any other medical interventions?

Have you consumed drugs or alcohol within the last 24 hours?

Are you pregnant / nursing?

Are you taking any daily medication?

Do you have any allergies?  

Codein

Do you use any medications or have any medical/skin conditions that may affect the healing of the body art you wish to receive?  

No
 

Contractual Obligations:

I agree to having my photo taken and will allow my technician to use the photos for advertising purposes on mediums such as, but not limited to, social media. Initial:

Despite the application of the most advanced and top quality pigments, allergic reaction is possible, but rare. You have been made aware of this and assume liability. Initial:

I understand that the highest standards of hygiene are met and that sterile disposable needles, containers and other disposable items are used for each individual client, procedure and visit to ensure cross contamination is eliminated. Initial:

 

During and after the procedure, temporary minor swelling, redness and/or itching may occur. Initial:

 

Depending on your skin structure, after the first treatment, a loss of pigment may occur and color intensity may change. In the first 7 days, eyebrows are up to 50% darker, and 10-15% thicker than the healed result. You have been made aware of this. Initial:

 

Depending on the skin structure it should be noted that changes in the color intensity are possible and more than one top up appointment may be required. The pigment is absorbed differently due to differences in the skin quality, thus there is no guarantee for treatment success. You have been made aware of this and assume liability. Initial:

 

Touch up fees may apply for future appointments if touch ups are desired. If most of the color has faded then this will not be considered a touch up and fees for a new treatment may apply. For oily skin it may be necessary to perform more corrections. Initial:

 

The minimum or maximum duration of microblading or permanent make up procedures cannot be determined with certainty. You have been made aware of this and assume liability. Initial:

 

The eyebrow shape is determined according to face proportions. No two sides of the face are symmetrical and whilst trying to obtain perfect symmetry is my goal, nothing is guaranteed. Initial:

 

Permanent makeup always leads to minor skin injury. During the procedure, despite my expertise and all precautionary measures, injury is possible. It is important to carefully and gently nurture your skin after the treatment to allow healing without complication. Please follow the care tips given to you. Inadequate care during the healing process can lead to poor results. You have been made aware of this and assume liability. Initial:

Permanent makeup is an art, not a science. Your results will vary and using a brow pencil or powder may still be needed, especially when wearing heavy coverage make up. Please remember that microblading is only an enhancement to your natural brows. This is not a ‘no maintenance’ treatment, but a ‘low maintenance’ treatment. Initial:

  

During the next 7-14 days, you are required to pay attention to the following:

Keep your eyebrows completely dry and clean for the next 7-14 days. It is normal for a film to appear on your brows during the healing process, but if you get them wet, scabs will appear and this can lead to your pigment fading / becoming patchy. Initial:

 

For post-treatment care, use only the recommended liquids to clean the brows. If skin is oily or sweaty, make sure you clean the skin whenever necessary. Please do not use products other than the recommended. If liquids/creams are applied which aren’t recommended, you risk infection and undesirable results. Initial:

 

Please do not exercise for at least 2 days after your treatment due to excess sweating. Gentle exercising up until day 14 is OK but no excess sweating. Initial:

No cosmetics or makeup on your eyebrows for 2 weeks - after 2 weeks is fine. No saunas or swimming for 2 weeks after your treatment - after 2 weeks is fine. Initial:

 

No sun beds, sunbathing, eyebrow tinting, chemical peels, mesotherapy, dermabrasion, botox or any other strong treatments for 4 weeks - after 4 weeks is fine. Initial:

Your technician is not liable in case of improper post treatment. No refunds will be given. I acknowledge there have been no guarantees made to me concerning the results of this procedure and the timeframe the results will last for. Initial:

 

I confirm I’ve read and understood the above information. I’ve received a clear and understandable response to all of my questions. The treatment and post treatment care has been explained properly and I understand it. An aftercare kit & instructions been given to me to take home. I understand the information given to me to me to take home, agree to it all, and am liable for the aftercare part of the treatment.

Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by Katelyn McCloy, your technician.

Is there any information you feel you should provide to the body artist?

None

 

Leave this empty:

Signature arrow

Signed by Katelyn McCloy
Signed on: April 9, 2018

Signed by Theresa Fisher McCloy
Signed On: March 25, 2018


Signature Certificate
Document name: Microblading Client Record - Katelyn McCloy
lock iconUnique Document ID: 66a3aa924bb2676322437a48726e33a6a6b325f3
Katelyn McCloy
Party ID: df36f626-0a24-4c70-b805-ed5a105fe2a3
IP Address: 104.60.142.208
Digital Signature:
Katelyn McCloy
Multi-Factor
Digital Fingerprint Checksum
1bb8555cbd6cbab383ec98dd7f95dfd4
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Timestamp Audit
April 9, 2018 10:17 am EDTMicroblading Client Record - Katelyn McCloy Uploaded by Katelyn McCloy - Katelynmccloy@icloud.com IP 72.215.205.213, 127.0.0.1
April 9, 2018 10:17 am EDTDocument signed by Katelyn McCloy - Katelynmccloy@icloud.com IP 104.60.142.208, 127.0.0.1
April 9, 2018 10:17 am EDTThe document has been signed by all parties and is now closed.