• Date of Birth*
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  • Brief Health History

    Ensuring microshading is safe for you!
  • Are you on any blood thinning medications?*
  • Have you ever had, experienced, or use one of the following:*
  • In the last 6 months, have you been taking any of the following medications:*
  • Have you ever had an allergic reaction to any of the following?*
  • Have you received chemotherapy or radiation in the past year?*
  • Do you have any autoimmune disorders?*
  • Have you ever had a cold sore or fever blister?*
  • Do you have any medical condition that has resulted in medical professionals requiring you to pre-medicate prior to invasive procedures?*
  • Do you scar easily?*
  • Do you bruise or bleed easily?*
  • Do you experience hypopigmentation or hyperpigmentation?*
  • Are you currently under the care of a physician?*
  • Are you pregnant or breast feeding?*
  • Have you had alcohol in the past 24 hours?*
  • Do you use tobacco?*
  • Do you intentionally tan you face?*

  • PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

    Microshading is a cosmetic tattooing procedure; touch-up sessions may be required. A healing period of 4-6 weeks is required before a touch-up procedure can be performed. On a rare occasion, the pigment may migrate under the skin. The Microshading procedure may be slightly uncomfortable. The pigments will fade. In the several days immediately following the procedure, the pigment may appear 30-40% darker than the desired result. Although extremely rare, there may be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure.Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be applied if you are pregnant or nursing, or anyone under the age of 18 (without parental consent). Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after Microshading procedure, you should notify/discuss with your doctor. Possible scarring may occur, but is extremely rare.
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  • Date*
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  • Informed Client Consent

  • What is "Permanent Makeup"?

    "Permanent Makeup" is the procedure of inserting pigment into the basement membrane layer of the skin, via a blade(s) or needle(s). The basement membrane is between the epidermis (superficial layer) and the dermis (deepest layer). Because this procedure is more superficial than a normal tattoo, it is considered semi-permanent, lasting from 1-3 years for eyebrows. As your skin naturally exfoliates over time, the permanent makeup (PMU) will inevitably fade and may require touch-up sessions for maintenance.

     

    What to expect


    Upon receipt of consent forms and health history, the artist will review the responses and ensure there are not any contraindications for the procedure. With consent, the artist will take before photos. You will then receive pre-numbing solutions, and speak with artist in regards to your eyebrow desires. You will then have your eyebrows mapped to find the shape in which the artist will follow during the procedure. The artist will then start with the procedure on the brows. Upon completion, the artist will review aftercare instructions with you, take after photos, and the complete financial transaction.

     

    Risks


    With the injection of pigment into the skin, the skin will open and there is a very small degree of risk for infection, although exceedingly uncommon. Every tool is pre-sterilized, disposable, and disposed of after use. Cross-contamination procedures are strictly followed. To avoid the risk of infection during healing process, it is important to strictly adhere to the aftercare instructions provided to you. 

    I have been informed that the highest standards of hygiene are met and that sterile, disposable needles and pigment containers are used for each individual client, procedure and visit.

  • Expectations for Results


    Results of procedure vary from client to client. Results vary due to client's individual health. lifestyle, and skin type. PMU is an art, not a science, and results cannot be guaranteed. Results will likely fade 30 - 40% by the end of the complete healing process (approx 30 days). In very rare cases, the pigment may diffuse in the skin. I accept the responsibility for determining the color, shape and position of the microshading procedure as agreed during consultation. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years. Even once the color fades, pigment itself may stay in the skin indefinitely.

    I understand and accept that each procedure is a process requiring multiple applications of pigment 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 result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, as well as adherence to post procedure after care. Upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume your normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed. Please see after care card for more details. I have been advised that the true color will be seen 1 month after the procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.

  • Allergies

    I understand that topical anaesthetic is used, and may contain lidocaine or other similar active ingredients. There may be nickel in tattoo needles and certain pigments, and may trigger allergic reactions in rare cases. A patch test is available,  it does not ensure a client will not have an allergic reaction. If waived, I release the technician from liability if I develop an allergic reaction to the pigment. If an unforeseen condition arises in the course of the procedure, I authorize my artist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances.

  • Booking Fee

    A booking fee of $50 is required to schedule an appointment for the procedure.

  • Today's charge will be...*

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      • Touch-Up


        I understand that the microshading procedure requires 2 visits (in some cases, more may be required). Scheduled appointment for the touch up procedure requires 48 hours notice for cancellation or rescheduling, and is included in the original price ONLY when performed within 6-8 weeks after the original procedure. Later than 6-8 weeks or if scheduled appointments are missed, an additional charge will be incurred. All touch ups performed after will be at Lexurious Brow's touch up rate.

      • Photo Consent


        By initialing, I consent to the use of my photos for the purpose of marketing. My pictures may appear in print or online. My photo may also be saved for documentation with my confidential client file.

      • Permission to Perform


        By Initialing, I give Kimberly Johnson  permission to perform microshading - permanent makeup procedure on my eyebrows.

      • Final Consent


        I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing, and desire to receive the indicated permanent pigmentation procedure. To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed has been explained to me. I acknowledge and agree with everything I have read thus far, and am willing and ready to continue with the permanent makeup procedure.

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      • Your Brow Preferences

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