Areola & Paramedical

Pre-Procedure Information & Consent Form

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Last Name

Phone *

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PLEASE READ

Pre-Procedure Instructions for Areola & Paramedical Tattoo Procedures

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 PARAMEDICAL 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.

NOTE: For Areola procedures 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 does not include Scar Correction/Camouflage, Tattoo Removal and Corrective work which are priced per session/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:

Areola:

Scar Camouflage

***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.***

Policies

In order to provide all of our clients with great service and the best experience, OUR POLICIES are as follows:

1. CLIENT-ONLY IN THE PROCEDURE ROOM: Though a friend or family may accompany you to your appointment, we have learned it is best that they do not sit-in on your procedure. It is important the artist is able to have their full focus on you, the client. Friends and family tend to be a distraction for both the client and artist.

2. CHILDREN, TODDLERS AND BABIES. Though we love children, toddlers and babies, we must kindly ask that you do not bring them with you to your appointment. Unfortunately, they are a distraction to the artist, as well as the other guests having services with Julie Michaud. Thank you for your understanding.

3. CANCELLATION POLICY: Micropigmentation is a time-intensive service. In booking your appointment, we are reserving a designated amount of time specifically for you. We require a 50% deposit in order to reserve this time for your appointment. If you need to cancel for any reason, we require that you cancel at least 72 hours prior to the start of your appointment time so that we may be able to offer this time to another client. If your appointment is cancelled with less than 72 hours notice (or in the case of a no-show), you will still be charged the full price of your scheduled service. There is no charge for the follow-up appointment to a new/initial procedure when it is done within 3 months of the initial procedure. However, in the case of a cancellation with less than 24 hours notice or a no-show, the follow-up is considered forfeited and any following appointments will be charged as a touch-up appointment.

4. TARDINESS: Please plan to arrive 15 minutes prior to the start of your appointment. If you are late it will compromise the amount of time the artist has to spend on your procedure, which in turn compromises your results. In the event that a client is more than 15 minutes late for cosmetics, and 30 minutes late for micro, the procedure may be cancelled, and the full service fee will still apply, as we are not able to sell this time to another client.

5. RIGHT TO REFUSE TREATMENT: Though it is extremely rare, we reserve the right to refuse treatment for the following reasons:

Undisclosed skin condition (including sunburn/suntan)
Under the influence of drugs or alcohol
Any behavior which, in the opinion of the artist, might compromise the artist’s ability to work safely and comfortably toward the desired results, or might disrupt other clients.

Please Complete This Section

Informed Consent for Areola & Scar Camouflage Tattoo Procedures

Medical Disclosure

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.

Additional Medical History for Areola Tattoo Procedure

Have you ever been diagnosed with or received treatment for breast cancer? *

Yes

Diagnosis

Date of Diagnosis

Which applies to you?

Bilateral

Unilateral

Nipple Graph

Radiation? *

Yes

Date of last radiation treatment

Chemotherapy? *

Yes

Date of last Chemotherapy treatment

Any complications or infections?

Yes
No

Type of reconstruction

The date of last surgery

Surgeon Information

Breast Surgeon Information

Reconstructive Surgeon Information

Oncologist Information

Have you received a letter from your practitioner approving you for this service? *

Yes

If yes, please upload a copy or bring it to your appointment.

PDF, PNG, JPEG, JPG, DOCX or DOC

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

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

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

I release the Julie Michaud from liability for adverse outcomes except in cases of gross negligence.

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 Paramedical Consent *

Clear