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Microblading Informed Consent and Release

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Microblading - Informed Consent and Release

This form provides information about microblading, which involves the application of semi-permanent makeup. You are encouraged to carefully review the information provided in order to make an informed decision as to whether to undergo the microblading procedure.

Microblading involves the insertion of pigment into the dermal layer of the skin and is a form of tattooing. Initially the color will appear more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40-50%, soften and look more natural. The pigment is semi-permanent and will fade over time and will likely need to be touched up within 12 to 18 months.

All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross contamination guidelines are carefully adhered to.

Generally, the results of microblading are excellent. However, a perfect result is not a realistic expectation. It is usual to expect a touch-up after the healing is completed.

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 "After Care" sheet for instructions on care.

• Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your follow up appointment will likely correct any uneven appearance.

• 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 disappears 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 now.

• Allergic Reaction: There is a possibility of an allergic reaction to the pigments or other materials used. You may take a 5-7 day patch test to determine this. Please initial to: Waive or Take .

The alternative to these possibilities is to use cosmetics and not undergo the microblading procedure.

Consent for Microblading Procedure: Please read and initial all lines.

I am currently not under the influence of any drugs or alcohol.

I am not pregnant.

I do not currently nor have I taken Accutane within the last 12 months.

I have not had Botox and/or other cosmetic filler procedures within the past two weeks.

I have not had surgery of any kind within the past six months.

I have not taken any blood thinning medication with the past 72 hours nor have I taken aspirin within the past 24 hours.

Aftercare instructions have been explained to me and are attached to this consent form. A written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions I will call or email my technician.

I have reviewed the Eyebrow Microblading FAQ prior to my appointment, and I understand the information listed there.

I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness and bruising may occur.

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 sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.

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 color can 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 within 8-12 weeks.

I acknowledge that the microblading procedure involves inherent risks and that there is a possibility of one or more complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation.

I have been quoted the cost of today’s appointment which includes one (1) touch-up within 8-12 weeks following today’s appointment. After 12 weeks, a fee will apply for any further touch-ups. There will be no refunds for this elective procedure.

Special instructions to the technician:

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 of my questions have been answered. I acknowledge that I have reviewed and approved the materials given to me and I authorize Kanha But Johnson to perform the microblading procedure on me. I hereby release Kanha But Johnson from any liability arising from the risks that are known and/or inherent in the microblading procedure.

Signature

Date

Name (Please Print)

Phone Number

Address

Email

Optional Photography Release Consent

We would like to take before and after photographs depicting the results of your procedure. We would also like your permission to use these photographs for advertising. Advertising may include portfolios, brochures, online or print advertisements, etc. Please indicate whether you consent to our use of your photographs for advertising purposes.

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What the Microblading Informed Consent and Release Covers

A Microblading Informed Consent and Release is a clinical consent form that documents a client’s voluntary agreement to receive microblading, records relevant medical and allergy information, and obtains authorization to proceed while acknowledging risks and possible outcomes. It typically includes procedure details, expected results and limitations, aftercare instructions, photography and pigment consent, and a release of liability or assumption of risk. The document also identifies who performed the service and establishes a dated record useful for clinical follow-up, dispute resolution, and regulatory compliance.

Why a Clear Consent and Release Matters

A complete consent and release clarifies expectations for both client and provider, documents informed choice, and reduces legal and regulatory risk. Properly executed forms support clinical decision-making, evidence collection if complications arise, and retention consistent with HIPAA and recordkeeping obligations. Electronic execution is generally enforceable under federal ESIGN law (15 U.S.C. §7001) and state UETA statutes where adopted.

Why a Clear Consent and Release Matters

Who Typically Completes and Signs This Form

The form is used whenever a microblading procedure is planned and serves multiple roles for clinical and business records.

  • Licensed technicians and studio owners: document training, consent, and liability allocation before any procedure.
  • Medical spas and supervising clinicians: integrate the consent with patient intake and medical history for clinical oversight.
  • Clients or legal guardians: confirm understanding of risks, aftercare, and follow-up responsibilities before signing.

Each signer should match identity documentation and complete all required fields to ensure the consent is valid and defensible.

Core Parts Every Professional Consent and Release Should Include

A professional Microblading Informed Consent and Release combines clinical disclosure, client health data, and legal language to record informed agreement and limit disputes.

Procedure Details

Describe the steps, expected sensations, pigment placement goals, approximate duration, and number of sessions or touch-ups typically required.

Risks & Complications

List common and rare risks—infection, allergy, scarring, pigment migration, poor retention—and steps to reduce those risks during and after the procedure.

Medical History

Capture conditions, recent medications, blood thinners, autoimmune disease, skin disorders, and prior cosmetic procedures that affect healing or outcomes.

Aftercare Instructions

Provide explicit post-procedure care steps, contact guidance for complications, restrictions (e.g., no swimming, saunas), and expectations for color changes.

Photography & Use

Obtain consent for pre- and post-procedure photos for medical records or promotional use, specifying permitted uses and withdrawal procedures.

Release & Acknowledgement

Include an assumption-of-risk and release clause, signature block, and a dated acknowledgement that the client understood the information provided.

Essential Data Fields to Collect

Full Legal Name: Exact name from government ID
Date of Birth: MM/DD/YYYY
Contact Information: Phone, email, and address
Medical History: Key conditions and medications
Allergies: Known allergies and reactions
Signature & Date: Signed by client or guardian

Step-by-Step: Completing the Consent in Clinic or Online

Follow a consistent sequence to gather information, explain risks, and secure a clear signature before any microblading work begins.

  • 01
    Pre-appointment Screening: Collect health history and photos prior to arrival.
  • 02
    Review Risks: Discuss complications, recovery, and touch-up expectations with the client.
  • 03
    Obtain Consent: Ensure client signs the consent and release in-person or via secure e-signature.
  • 04
    Document Aftercare: Give written aftercare instructions and record client acknowledgement.

Where the Completed Form Should Be Stored and Who Receives Copies

Establish a standard routing path so signed consents are accessible for clinical care, regulatory inspection, and client reference.

  • Clinical Record: Store the signed form in the client’s medical or treatment record.
  • Secure Electronic Archive: Retain a copy in encrypted electronic storage accessible to authorized staff.
  • Client Copy: Provide the client a dated copy (print or secure PDF).
  • Regulatory/Legal Requests: Produce records for inspections or legal inquiries as required.

Configuring an Online Consent Workflow

Design the online flow so required fields, identity checks, and audit trails are enforced before the final signature.

Field Configuration
Signature Field Required; date auto-populates on sign
Identity Verification Email plus SMS code or stronger authentication
Attach Medical History Allow PDF/image uploads for prior records
Audit Trail Enable timestamps, IP, and action log

Technology and Security Considerations for eSigning

Choose a platform that supports secure storage, verifiable audit trails, and appropriate authentication for health-related consents.

  • File Formats: PDF and DOCX supported
  • Authentication: Email+SMS or stronger
  • Encryption: TLS in transit, AES-256 at rest

Consequences of an Incomplete or Incorrect Consent

Clinical Harm: Increased risk of infection or adverse reaction
Allergic Reaction: Severe reactions requiring medical care
Civil Liability: Potential malpractice or negligence claims
Licensing Action: Disciplinary measures from boards or commissions
HIPAA Violation: Fines and corrective action for PHI breaches
Record Loss: Inability to defend care without retained records

Common Errors to Avoid When Preparing the Form

  • Incomplete medical history entries that omit blood thinners or immune conditions can increase clinical risk and liability.
  • Unsigned or undated forms create evidentiary gaps and may invalidate the consent in disputes.
  • Mismatched names between the consent and photo ID hinder identity verification and may undermine enforceability.
  • Poor storage practices—unencrypted email or unlocked folders—expose protected health information and violate privacy standards.

Practical Steps to Improve Accuracy and Compliance

Adopt consistent administrative and clinical practices to reduce risk and improve patient understanding.

Confirm Identity
Verify client identity with government ID and record the document used. Keep matching name fields to prevent disputes and ensure the signer is the person who received the procedure.
Record Allergies Clearly
Document allergy type, reaction severity, and last occurrence in detail. Explicit allergy records aid safe clinical decisions and provide critical evidence if complications arise.
Provide Written Aftercare
Give client printed or electronic aftercare instructions and document that the client received and acknowledged them. Clear instructions reduce complication risk and subsequent liability.
Use Secure eSignature
Choose a platform that records an audit trail, supports required authentication, and provides encrypted storage to protect PHI and demonstrate consent validity.

Illustrative Use Cases from Typical Studios

Two concise scenarios show how a signed consent operates in common microblading workflows.

Independent Studio

A client completes the intake online before the appointment to speed check-in and allow the technician to review medical risks.

  • Technician documents pigment selection and touch-up plan.
  • The studio retains the signed PDF in the client chart and provides a client copy by secure email for reference and aftercare compliance.

Med-Spa Clinic

A med-spa integrates the consent into its electronic health record and links photographs to the record for comparison.

  • Clinician reviews allergies and documents topical anesthetic use.
  • Signed records support clinical oversight and are retained under HIPAA rules for six years.

Electronic Signature vs Digital (PKI) Signature

Understand the technical and legal differences so you can choose the right signing approach for clinical consent and regulatory needs.

Characteristic Electronic Signature Digital Signature
Definition any electronic sound or symbol cryptographic pki-based signature
Technology image/typed/click-to-sign x.509 certificate, pki
Legal Acceptance broad under esign/ueta strong technical non-repudiation
Typical Use general consents and contracts high-assurance regulatory needs

eSignature Platform Pricing Comparison

Typical starting prices and feature highlights for popular eSignature vendors. signNow is listed first per comparison conventions.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions About the Consent and Release

Answers to common questions about validity, minors, storage, and handling complications.


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