Permanent Makeup

Pre-Procedure Information & Consent Form

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Pre-Procedure Instructions for Micropigmentation (Permanent Makeup)

Contraindications:

You are not a candidate for micropigmentation if any of the following apply to you:

Pregnancy
Nursing
Diabetes Type 1
Lupus
Hepatitis B/C
AIDS
Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis, Pink Eye, Sun Burn,
Severe Acne
Active Vitiligo
Severe Rosacea
Blood Disorders: Sickle Cell, Hemophilia
Keloid Formation
Mental Disorder
Accutane (must be off for 12 months)
Steroids (must be off for 6 months)

Restrictions:

Retinol/Retin-A must be discontinued 7 days prior to procedure. (It will cause the skin to bleed).
Injections (Botox, Radiesse, JuvaDerm, Voluma, etc.) must be done 2 weeks before or 2 weeks after the procedure.
Chemical peels and laser treatments may not be done within 60 days before or after the procedure.
The use of Latisse® must be discontinued at least 3 months prior to your eyeliner procedure (it creates an inflammatory response, causes excess bleeding and prohibits the eyeliner from healing well).
Sunburned or Suntanned skin is damaged skin and therefore will cause excessive bleeding. We CANNOT work on sunburned or suntanned skin.
You cannot expose the area to the sun for 30 days before or after the procedure.
Do not schedule this procedure within one week prior to a water vacation.
Stay out of steam rooms, saunas, hot yoga, swimming pool, etc. for one week following procedure.
Avoid sweating for 1 week post procedure (sweat will prevent pigment from healing into the skin).
Avoid alcohol and caffeine 1 day before the procedure to minimize any oozing, bleeding or swelling.
Do not take aspirin, ibuprofen, niacin, fish oil or vitamin E 3 days prior to procedure unless medically necessary.

Healing Expectations:

ALL SEMI-PERMANENT COSMETIC PROCEDURES ARE MULTI-SESSION PROCESSES. An initial application is incomplete until after a follow-up appointment, which must be scheduled approximately 6-10 weeks after your initial appointment. There is no additional charge for the follow-up appointment after your initial application as long as it is performed within three months of the initial application. (This excludes Scar Correction/Camouflage, Areola work, Tattoo Removal and Corrective work which are priced per hour.)

WHILE YOUR SKIN HEALS, BE PREPARED FOR THE COLOR INTENSITY OF YOUR PROCEDURE TO BE SIGNIFICANTLY LARGER, SHARPER, BRIGHTER, OR DARKER than what is expected for the final outcome. This is a normal and expected result of the application and healing process. The healing process will take a number of days to complete, depending on how quickly the outer layer of your skin exfoliates and new skin regrows to take its place. Since delicate skin or sensitive areas may swell slightly or redden, some clients feel it best not to make social plans for a day or two following any procedure.

Pre-Procedure Instructions:

Eyebrows:

Avoid tweezing, waxing, electrolysis, and coloring your brows for two weeks prior to the procedure. This will allow your technician the most flexibility to achieve optimal results.
Please be aware that we will remove your foundation and concealer to determine your true undertones. This is vital for us to choose the right color.
We offer several different options of eyebrow pigmentation lasting from several months to several years. (Microblading vs. traditional micropigmentation). We offer hair strokes, hair strokes with shading and fully shaded brows. Your specialist will discuss the best options for you depending on your skin type, lifestyle, desired results and desired maintenance.
Rest assured, we use the best tools and the best pigments in the industry.

Eyeliner

Do not wear contact lenses during or immediately following your eyeliner procedure. Remember to bring your glasses. You may resume wearing your contact lenses as soon as your eyes return to their pre-treated condition.
The use of Latisse® must be discontinued at least 3 months prior to your eyeliner procedure. Latisse® produces an inflammatory reaction in the skin, which causes excessive pain and bleeding. If you use Latisse®, your eyeliner will not take properly.
Do not use other growth stimulants such as RapidLash®, or RevitaLash® for at least one week prior to or one week after your eyeliner procedure.
Lash extensions must be removed completely before your eyeliner procedure. If you have lash extensions, we will not be able to do your eyeliner. Lash extensions pose a danger to your eyes during the micropigmentation procedure.

Lips:

If you have any history of cold sores, fever blisters, or herpes simplex, you must contact your physician to obtain and take the proper prescription medication to prevent such outbreaks for at least 4 days before and after the procedure.
Many physicians prescribe 12 capsules of 500mg Valtrex. Follow your physician's instructions.

***Micropigmentation is a process. Two or three sessions may be required to achieve the desired results. It is not uncommon to lose up to 70% of the color after the first session. Please be aware that having a procedure done while on your menstrual cycle can make you hypersensitive at the procedure site. You will be given detailed after-care instructions at the time of your procedure.***

Please Complete This Section

Informed Consent for Micropigmentation (Permanent Makeup)

The nature and method of the proposed semi-permanent makeup (cosmetic tattoo) procedure has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling.

Fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Fading or loss of pigment may occur. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur.

I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:

I have previously completed a Client Medical Profile Form for Julie Michaud. *

Yes, and it is up-to-date and correct

Yes, but I need to update it

No, I have not completed a Client Medical Profile yet

* If you need to update or have not completed one, you will be re-directed to the Client Medical Profile form upon submission of this consent form.

I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the pigments, dyes, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible. *

I agree

I acknowledge that complications as a result of permanent makeup procedures may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications. *

I agree

I realize that my body is unique and neither Julie Michaud nor its employees or contractors can predict how my skin may react as a result of the procedure. *

I Agree

I acknowledge that the procedure may result in a long-lasting (many years) change to my appearance and that no representations have been made to me as to the ability to later change or remove the results. *

I Agree

I understand that future skin altering procedures such as laser treatments, plastic surgery, implants, and/or injections may alter and degrade my semi-permanent makeup, and that I must inform any future service provider that I have had micropigmentation applied. I understand and accept that such changes are not the fault of Julie Michaud or its employees or contractors. I further understand that such changes or degradation in my appearance may not be correctable through further semi-permanent makeup procedures. *

I understand

I acknowledge that obtaining the semi-permanent makeup is my choice alone, and I consent to the procedure and to its attendant risks, and to any actions or conduct of Julie Michaud and its employees and contractors reasonably necessary to perform the procedure. *

I agree

I understand that I will have the opportunity, within the time constraints of my appointment, to approve the design and color of the semi-permanent makeup to be applied, and I accept responsibility for same. *

I understand

I have disclosed any medical conditions that may affect the healing of my skin pigmentation. If I have ever had cold sores (fever blisters, herpes simplex), I will consult with and strictly follow my doctor's instructions before contemplating any permanent cosmetic procedure around my lips.

I agree

Previous Micropigmentation

I have previously had micropigmentation performed by someone other than Julie Michaud on the same area (brows, lips, etc) that I am looking to have work on today. *

YES

I understand that correcting or touching up micropigmentation that was performed by others involves additional risks because of the existence of permanent pigments of unknown composition, brand, color, age, shape and other factors over which Julie Michaud has no control. *

I understand

I understand that additional appointments after the initial and followup appointments may be required, and will be billed at the companies standard rates *

I understand

I understand that Julie Michaud can not predict the results in advance and can not guarantee and has not represented that the results will be as I desire. *

I understand

I understand and fully accept the risks associated with this procedure and hold Julie Michaud harmless from same *

I understand

Media Consent

I consent to any relevant photographs being taken both before and after the procedure, to document the results of the procedure strictly for internal use. *

I consent

I consent to Julie Michaud using non-personally-identifying “before & after” photos of me for marketing purposes to display its capabilities and results. If I do provide consent, I may at any time withdraw such consent for specific photographs by contacting Julie Michaud, which will then discontinue use of said photo(s). *

Yes

No, I do not want my photos shared.

Informed Consent & Liability Waiver

I have been given the full opportunity to ask any and all questions which I might have about obtaining semi-permanent cosmetic procedures from a micropigmentation specialist at Julie Michaud, and that all of my questions have been answered to my full and total satisfaction.

I have read the pre-procedure instructions and I will strictly adhere to post-procedure instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure.

I acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself.

I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s).

I hereby release and forever discharge and hold harmless Julie Michaud, employees and affiliates from any and all claims, damages or legal actions arising from or connected in any way with my micropigmentation, or the procedure and conduct used in my performing my tattoo, to the fullest extent allowed by the law.

This contract is to remain in effect for as long as I remain a client of Julie Michaud and all its contents apply whenever work is being performed on myself. It is my responsibility to inform Julie Michaud if any changes have occurred in my medical history.

By signing this form I acknowledge that I have read and understand the contents of each statement above. *

I agree

Signature for PMU Consent *

Clear