Disclosure and Consent for Intradermal Cosmetic Procedures: Specifically Microblading

Participant's Name

Participant's Date of Birth

Participant's Information

Procedure Requested: Microblading

*We follow the HIPPA guidelines. HIPPA is the Federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative cost.


For Permanent Makeup Intradermal Cosmetic Procedures:

We are so pleased to have you as a client and we look forward to providing you a wonderful service.

I understand that if I have an infection, adverse reaction, or allergic reaction to the procedure, I must notify a healthcare provider and the Texas Department of State Health Services at (512)834-6626. 

I have read, the above post-procedure instructions and FULLY understand the information contained therein.

I agree to (circle one): Receive release Tawana Deas and its Representatives, 

Waive a spot test prior to application and I agree to 

Assistants, and pigment manufacture(s) from any and 

all liability related to allergic reaction or any other reaction to applied pigments. 

I have been told that this procedure may involve pain and discomfort. 

I understand the markings are permanent and that there is the possibility of hyperpigmentation resulting from the procedure, especially in individuals prone to hyperpigmentation from scar or other injury. 

I understand that a follow-up procedure may be required. 

I understand other risk involved with the procedure may include, but are not limited to: infections, allergic and other reactions to applied pigments, allergic and other reactions to products applied during and after the procedure, fanning or spreading of pigments (pigment migration), fading or 


I accept FULL responsibility for any and all, present and future, medical treatments and expenses I may incur in the event I need to seek treatments for any known or unknown reason associated with this procedure. 

I have been given the opportunity to ask questions about the procedure(s) to be performed/used and the risks and hazards involved, and I believe that I have sufficient information to give informed consent. 

I agree that should I have a complaint of any kind whatsoever, I shall immediately notify Tawana Deas, and I further agree that any controversy or claim arising out of or relating to this consent and/or any signed contract between myself and Tawana Deas or the breach thereof, shall be settled by Arbitration in the state of Texas in accordance with the Rules of the American Arbitration Association and judgement of the award rendered by the arbitrator(s) may be entered in any court that has jurisdiction. 

I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify Tawana Deas, a healthcare provider and the Texas Department of State Health Services.