This form provides information about microblading, nano brows, and lip blush, which involves the application of permanent make-up. You are encouraged to carefully review the information provided to make an informed decision as to whether or not to undergo the permanent make-up procedure. This involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing. Initially, the colour will appear more vibrant and/or darker compared to the end and healed result. Usually within 7 days the colour will fade 40-50%, soften, and look more natural. The pigment will fade over time, and will likely need to be touched up within 12 - 18 months for microblading, 1 - 3 years for nano brows and lip blush. All instruments that enter the skin or encounter body fluids are sterilized, disposable and disposed of after each use. Cross contamination guidelines are carefully adhered to. Generally, the results of cosmetic tattooing are excellent. However, a perfect result is not a realistic expectation - it is usual to expect a touch up after the healing is complete.
Possible Risks, hazards, or complications:
- PAIN: There is a possibility of pain or discomfort even after the topical anesthetic has been used. Anesthetics work better on some people than others.
- INFECTION: Although rare, there is a risk of infection. The areas treated must be kept clean and only freshly cleaned hands should touch the areas. See the "Aftercare" page for instructions.
- UNEVEN PIGMENTATION: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearances.
- 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 SWELLING OR BRUISING: Some people bruise and swell more than others. Ice packs may help, and the bruising and swelling typically disappear within 1 - 5 days. Some people don't bruise or swell at all.
- ANESTHESIA: Topical anesthetics are used to numb the area to be tattooed. 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 immediately.
- ALLERGIC REACTION: There is a possibility of an allergic reaction to the pigments or other materials used. You may take a Scratch Test to determine this.
- The alternative to these possibilities is to use cosmetics and not undergo this procedure.
Consent Form for Permanent Make-Up
Please read and insert your initials if all the following statements are true:
- I am currently not under the influence of any drugs or alcohol.
- I am NOT pregnant or nursing.
- I do not currently take, nor have taken, Accutane within the last 12 MONTHS.
- I have not had Botox and/or other cosmetic filler procedures within the past 2 WEEKS.
- I have not had any surgery of any kind in the past 6 MONTHS.
- I have not taken any blood thinning medication within the past 72 HOURS, nor have I taken Aspirin within the past 24 HOURS.
- Aftercare instructions have been explained to me and can be found at www.Barbieworldspa.com/aftercare which I will follow to the best of my ability. A written copy can be given to me upon my request to be kept in my possession. If I have any questions, I will contact my technician.
- I understand the necessity for following these aftercare instructions and understand that if it is found to be by Barbie World that aftercare instructions are not followed intentionally or otherwise, that any future procedure, including no charge follow-up visits, will not be completed and that I may be dismissed as a Barbie World client. No refund of any procedure will be given. Barbie World has the best interest of the client and cannot risk the liability of a client willing to sacrifice result with improper care.
- I will contact my physician if I notice any infection beginning to form.
- 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 the sun, tanning beds, pools, some skincare products, and medications may affect my cosmetic tattoo.
- I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure done today.
- I understand that implanted pigment may change or fade over time due to circumstances beyond the salon's control, and I will need to maintain the color with future applications and a touch-up session in 6 - 12 weeks.
- I acknowledge that the cosmetic tattoo procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedure, such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.
- I have been quoted the cost of today's appointment, which includes (1) touch-up within 6 - 12 weeks following today's appointment. After 12 weeks, a fee will apply for any further touch-ups. There will be no refund for this elective procedure.
- I 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 my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Eleonora Potapova to perform the cosmetic tattoo procedure on me. I hereby release Eleonora Potapova, and Barbie World and its affiliates from any liability arising from the risks that are known and/or inherent in the cosmetic tattoo procedure.
Optional Photo Release Consent
Eleonora Poutilova would like to take before and after photos depicting the results of your procedure. In order to do so, your permission is needed for advertising with these photographs. Advertising may include portfolios, brochures, online or print advertisements, etc. Please select "Yes - Full Face", "Yes - Eyebrows and Eyes Only" or "No" below to indicate whether or not you consent to our use of your photographs for advertising purposes.
Client's details
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Appointment Details
Please list all medical conditions, medications and/or allergies (N/A if none)
Scratch Test
Barbie World offers scratch tests 48 hours prior to procedure. If you have concerns about allergies and would like a scratch test performed, please contact us at saja@barbieworldspa.com. Skin allergy testing, or skin prick test, is a method for medical diagnosis of allergies that attempts to provoke a small, controlled allergic response. With cosmetic tattooing, there is a rare chance of a reaction. By not performing a scratch test, you are made aware and consent to this possible risk. Please let it be known that regular body ink is a different compound than cosmetic tattoo/permanent makeup ink. If you have had a tattoo in the past and feel "safe" getting your procedure, be advised that they are two different ink compounds - you could be reactive to one, but not the other.
By clicking YES, you agree to participate in a Scratch Test & have contacted Barbie World at saja@barbieworldspa.com 48 hours prior to your procedure to schedule a Scratch Test.
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