Babe with Blade, Inc.                                                 SMP Consent & Release Form
By booking an appointment you acknowledge having read and agree to both the Booking Policy and Pre- Treatment Instructions.
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Email *
I understand that I will be receiving a semi-permanent cosmetic procedure, Scalp Micro-pigmentation, 3D Hair Strokes/ hair stubble, which enhance the hair/ hairline. *
Required
I understand this procedure has had results for some clients that have lasted 2 to 3 years, but these results vary and I understand that no timeframe is guaranteed to me. *
Required
I understand Scalp Micro-pigmentation is a cosmetic semi-permanent tattoo and while, with time, pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, and use of chemicals such perms, dyes etc.. this is semi-permanent. Touch-up maintenance work will be expected in the future to keep it looking fresh. *
Required
I acknowledge that no guarantees have been made to me concerning the results of this procedure and agree that the professional recommendation is a “natural look.” *
Required
I understand that there are some common possible complications of Scalp Micro-pigmentation including headache, redness, allergic reactions, tenderness, infection, migration. In addition, I understand that there is a possibility of hyperpigmentation or scarring resulting from a procedure, especially in individuals prone to hyperpigmentation from a scar or other injury. *
Required
I understand that it is normal to lose approximately 1/3 of the color during the healing process. I realize that after the procedure the color will appear to be darker and that in about 7 days the color will appear in its final form and will appear softer. *
Required
I realize there will be a period of time when scabs may form and the skin may slough/flake off and that I am not to touch the areas during this time. Picking at, pulling or scratching off or otherwise removing sloughing skin may result in loss of color. *
Required
I understand the nature of the procedure and possible complications or adverse effects that may occur as a result of applied pigments. *
Required
I understand that I will receive and will acknowledge pre and post procedure instructions and agree to strictly adhere to such instructions. I understand that achieving the results I desire will, in some measure, be determined by my compliance to aftercare instructions. *
Required
I accept responsibility for approving the color of the pigments and shape that will be applied and will approve such applications before the procedure begins. I understand that actual color of pigment may be modified slightly due to the tone and color of my skin and that because of the elasticity of the skin the shape may change slightly from that which I originally approved. I also understand that pigment unpredictably attaches to some area of the skin more intensely than other areas and may appear darker or lighter than originally intended. However, I know that every effort will be made to make the final result flawless. *
Required
I will inform Babe with a Blade, Inc. and Nicole DaCosta of any condition which may make any of the procedures contraindicated including recent hepatitis or pregnancy, medications, health issues, or personal issues. *
Required
I understand the taking of before and after photographs of procedures maybe required and that some photographs maybe taken during the procedure. I also understand that exceptional photographs or results may be used in advertising or promotional materials and give permission for such usage. *
Required
I have been given an opportunity to ask questions about the procedures, equipment, past experiences, and/or the method to be used as well as the risks and hazards involved and I believe that I have sufficient information to give this informed consent. *
Required
Consent Form Acknowledgment
By signing the customer wavier and release agreement, I the client names below certify that I knowingly and voluntarily release Babe with a Blade, Inc. and Nicole DaCosta and it’s directors officers owners employees agents and representatives from any and all claims for damages for personal injury arising from the application and procedure of Scalp Micro-pigmentation, 3D Hair Strokes/ hair stubble, including damages relating known or unknown complications which may arise during or following the application process including but not limited to claims from negligence. I further release and hold harmless Babe with a Blade, Inc. and Nicole DaCosta from any claims related to preexisting conditions I have not revealed or changes to those conditions subsequent to the procedure.  I (client listed below) certify that I have read and fully understand this customer wavier and release agreement. I hereby authorize Babe with a Blade, Inc. and Nicole DaCosta to provide semi-permanent cosmetic procedure, Scalp Micro-pigmentation, 3D Hair Strokes/ hair stubble onto my own natural hair and hairline/ skin, in accordance with the terms and conditions set forth in this customer wavier and release agreement.
Name (by typing your full name you are acknowledging that this is an E-signature and that all information provided in true) *
Date of Service *
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Phone number *
Client Medical History Form
Do you presently have or previously had any of the following: (check box if yes) *
Required
Chemical Peel (last treatment)
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Cancer (year)
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Chemotherapy/ Radiation
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Tumors/ Growth/ Cysts
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Any diseases or disorders not listed?
Clear selection
Name (by typing your full name you are acknowledging that this is an E-signature. You agree that all the information listed in the above "Client Medical History Form" is true and accurate to the best of your knowledge. *
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