Microblading Consent Form

Clients Full Name:  



Contact number:   

I hereby authorize Jameelah Lloyd – Owner of Spa Shal’vah to perform upon myself permanent cosmetic
enhancement. If any unforeseen condition arises in the course of the procedure(s) I further request and
authorize her to use her full judgement and do whatever he/ she deems advisable and necessary in the

I agree that I have FULLY read the Before & Aftercare & Qualifying Client Information for Permanent Eyebrows “Microblading” at www.SpaShalvah.com as directed by Spa Shal’vah (Jameelah) prior to booking
my appointment & fully agree that I qualify for Microblading Permanent Cosmetics & agree to follow all of the Before & Aftercare instructions as it its solely my responsibility to do so

I understand that Spa Shal’vah specializes in “streamline shape brows” as seen on Spa Shal’vah’s IG/FB pages and website. Clients requesting brow shapes or patterns not favorable to client or artist (Jameelah) professional
opinion will NOT be done as permanent eyebrows “Microblading” & appointment may be DECLINED by Spa Shal’vah (Jameelah) without refund at any point during the set appointment time/day. To cut down on client
indecisiveness on desired brow shape/placement, a maximum of (1 hour) will be given to Brow Map Client desired brows – afterwhich the appointment may be declined/cancelled

I agree & understand that any point during my Microblading session Spa Shal’vah (owner Jameelah) reserves the right & may DECLINE to do Microblading services for any reasons such as but not limited to: Client
behavior/ Client being Intoxicated or under influence of any drugs /discovering Client falsifying own medical history pertaining to being a Qualified Client /failure to FULLY read required before/aftercare instructions / Client not being a good Microblading candidate (client is responsible for knowing this before booking appt)

I understand that in the event my Microblading appointment is DECLINED (by Spa Shal’vah ownerJameelah) during my microblading appointment, due to but not limited to the reasons listed above, I agree that my non-refundable $100 deposit will cover the time booked for my appointment day / DECLINED

I understand and accept that there are NO REFUNDS NOR CREDIT GIVEN FOR OTHER SERVICES for any Spa Shal’vah services rendered – including but not limited to “Microblading” Permanent Eyebrows.

I understand that permanent cosmetic enhancement is an advanced form of (permanent) tattooing

I understand and accept that (2) sessions are normally required to complete Microblading depending upon client skin type/diet/medicine taken by client. The Microblading FULL PRICE as stated online at time of client
booking and paid by client during the 1st initial session covers ONLY THE 1ST SESSION OF MICROBLADING. ADDITIONAL “Touchup Sessions” NEEDED BY CLIENTS ARE NOT INCLUDED IN
THE FULL PRICE NOR ANY DISCOUNTED SPECIAL PRICES. ALL “Touchup Sessions” are at ADDITIONAL CHARGES RANGING FROM $100 – $350. Prices are SET & NON NEGOTIONALABLE. I understand and accept that client failure to maintain any set “touchup sessions” appointments with or without proper notice of appointment cancellation forfeits any FREE or REDUCED PRICED “touchup sessions”. Additional fees may apply for touchup sessions scheduled past 10weeks post 1st session (updated rates on
website at www.spashalvah.com)

I understand that Microblading is a COSMETIC INVESTMENT which may require more than (2) sessions to complete depending upon client skin-type/client aftercare/medications taken; additional sessions are not
covered in initial price paid at 1st session

I understand and accept that all fees paid for the 1st initial Microblading service (be-it any FULL PRICE or any “special” promotional priced fee) covers the 1st initial Microblading service ONLY; the 2nd session “touchup session” is offered FREE if the FULL PRICE is paid by client -or- it is offered at an additional fee if a “Promotional/Special” fee is paid – which is due at 2nd session & listed in promotion/special; there are NO “refunds” for missed 2nd sessions for Microblading for any reason, as this 2nd session service is either FREE – or- paid at 2nd session

I accept and understand that after my eyebrow mapping (drawing) consultation is complete, a 3-point “client Consent check” is done where every client is given (3) opportunities to view their new eyebrow “mapping” in
mirrors (hand held mirror/walled mirrors & bathroom mirror) to ensure client 100% agreement to newly drawn on eyebrows Shape/Placement/Size/etc BEFORE signing final Consent Form & before Microblading
will begins

I accept 100% responsibility for choosing the color, shape and position of my (client’s) drawn-on eyebrow “mapping” & Microblading enhancement as agreed during the course of my eyebrow mapping consultation

“1-year touch-ups” are required to Maintain the Microblading look; yearly touchups must be no further than (1) year plus (2) months following initial Microblading procedure will be at a cost of $350 for the 1yr “touch-

I understand Microblading is NOT considered “healed” (true shape, size, color) until the 4th week after each session; the skin goes through many healing stages of scabbing/pealing/fading/pigment resurfacing during the
1st four weeks after each session

I accept 100% responsibility for both BOOKING & MAINTAINING (each) future required Microblading“touchup sessions” appointment. Under no circumstances is Spa Shal’vah owner or anyemployees/commissioned associates/affiliates responsible for booking nor contacting clients to book their future required Microblading “touchup sessions” for Microblading upkeep: this is includes but not limited to 6-9 week touchups/10week-6month touchups/yearly touchups

I understand that a sensitivity test for pigment does not guarantee that I will not have an allergic response. I am aware of that allergic response to pigment is rare and accept all responsibility if allergic response occurs

I am aware that a sensitivity reaction to anesthetics can occur and accept all responsibility if allergic response occurs

I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over the course of 1-3 years. Even though the color has faded, the pigment will
stay in the skin indefinitely and may leave a light residue of color. I understand that Oilier skin & Heavy Bleeders may show less retention & more “blurred lines – powdered brows”.

I understand that dyes, inks and pigments are not approved by the Food and Drug Administration (FDA) and the health effects are not known

I accept that the highest standards of hygiene are met, and that sterile disposable needles & client contactsupplies are used for each individual client, procedure and visit

I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results, and that 100% success cannot be guaranteed. I understand that this is why I need to return
for “touch-ups” of which is not included in the initial price (unless otherwise stated by Spa Shal’vah owner)

I understand there is NO SWEATING & NO GETTING EYEBROWS WET within the 1st (10 Days) following Microblading sessions (including Touchup sessions).

I understand that the pigment may migrate under the skin, however this is a rare occurrence. Sweating in first (10 days) while new Microblading brows are healing may increase chances of this migration to occur

I understand that permanent cosmetic enhancement is an invasive procedure and the infusion process (implanting pigment into the dermis layer of the skin with microneedles) can be uncomfortable

I am aware that the result of the procedure is determined by the following:
Nsaids & other medications which “thin the blood” & cause excessive bleeding
Skin Characteristics – i.e. dry/oily/sun-damaged
Natural skin undertones
Alcohol intake and smoking
General stress
A compromised immune system
Poor diet
Post procedure care treatment

I have been advised that upon completion of the procedure there may be swelling and redness of the skin, which will subside within 1-4 days dependent on lifestyle. In some cases bruising can occur. I have been advised that
I can resume normal activities immediately following the procedure, however, using cosmetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited for up to two weeks (10 days) following the infusion process

I understand that immediately after the procedure the enhancement can be 30 to 50% darker than the desired result and can take between 1-3weeks to lighten. I understand that the true color/shape/size will be visible (no
sooner than) approximately 4-5weeks after each Microblading session, and that the color may vary according to skin tones, skin type, age and skin conditions. I appreciate that some skins accept color more readily than
others and no guarantee of an exact effect or color can be given

I am aware that if I have had a previous eye disorder or eye infection and receive an eyelash enhancement, the disorder may reoccur again. I agree to use the correct medication to prevent such a disorder reoccurring. It is
advised to remove contact lenses PRIOR to arrival for all Permanent Cosmetic services

I understand that there are few effective methods for pigment removal. Laser removal has proven successful, however is a process

I agree to inform my doctor of my permanent cosmetic enhancement if I require a MRI scan within a 3 month period of receiving the procedure

I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the practitioner. I understand that infection and possible scarring can occur if I do not adhere to the said

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. I am at
least 18 years old. I understand a copy of my ID is required to receive any permanent cosmetic makeup procedures by the state of California. I am not under the influence of drugs or alcohol

I consent and understand that all clients receiving services at Spa Shal’vah are subject to audio & video recordings upon entering premises; as Spa Shal’vah and it’s perimeters are equipped with recording security
cameras & Echo “Alexa” A.I. system

For the purpose of documentation: I consent to the taking of “before” and “after” photographs of said procedure(s)

I understand that this description of the procedure is not meant to scare or alarm me. It is simply an effort to make me better informed so that I may give or withhold my consent for this procedure


I have viewed & fully agree to the DRAWN ON PATTERN, SIZE, THICKNESS & ULTIMATE PERMANENT EYEBROW SHAPE of my new “microblade/micropigment” permanent eyebrows in which Jameelah (Spa Shal’vah) has outlined/drawn for my new eyebrows on this (Date and Time)   

Client before & after Photography consent:
Subject to, the agreed design being shown to myself, as well as digital photographs,

   (Clients Name) sign to say this is a true picture of the
template of what design is required. I sign also to digital photos being taken immediately after my treatment so that there is a true comparison between what was requested and what was delivered.

‘I declare that I give my full consent to the tattooing being carried out by the aforementioned practitioner. I confirm that potential complications, e.g. infection and swelling, for the procedure
undertaken, and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my
responsibility to read this and follow the instructions on it, until the site has healed. I confirm that the above information provided by me for this consent form is correct to the best
of my knowledge

Full Name:  


Medical Health Release Form



Date of Birth:  


Home Phone:  

Work Phone:  





Physician’s Name:  

Phone Number:  

Physiciann’s Address: 




List all the medications you have been taking in the last 6 month

Have you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol?

Have you received chemotherapy or radiation treatment in the last year?


Name of Doctor:  


Allergies: have you ever had an allergic reaction to any of the following:

Anesthetics (which ones):   

Other allergies (list):  

Have you had a dental injection to numb your mouth? 

Are you presently pregnant or breast feeding?  

MRI scan scheduled in the next 3 months:  

Laser or IPL scheduled in the next 3 months:  

Do you give blood?  

Prior to dental procedures do you receive antibiotic therapy?   



Leave this empty:

Signed by Jameelah Lloyd
Signed On: May 31, 2019

Spa Shal'vah https://spashalvah.com
Signature Certificate
Document name: Microblading Consent Form
Unique Document ID: 3f88469bc34a7cd5b8fe9680ca40b2b40d72ee72
Timestamp Audit
October 13, 2018 6:46 pm GMTMicroblading Consent Form Uploaded by Jameelah Lloyd - spa.shalvah1@gmail.com IP