Microblading/Microshading Consent Form

Date *

Date

DOB *

Date

Full Name *

First Name Last Name

E-mail *

Phone Number *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

How did you hear about Fierce Beauty Boutique? *

Friend/Other

History of MRSA? (Methicillin-resistant staphylococcus aureus, a bacterium that causes infections in different parts of the body and can be very contagious) *

yes no

Botox? *

yes no

If yes, last treatment?

Keloid scars? *

yes no

Diabetes? *

yes no

Hepatitis (A,B,C,D) ? *

yes no

Surgical forehead/brow lift? *

yes no

If so, when?

Easy bleeding? *

yes no

Facelift? *

yes no

If so, when?

Easy hyperpigmentation ? *

yes no

Alcoholism ? *

yes no

Have any heart conditions or are you on a pacemaker or defibrillator? *

yes no

Chemical Peel ? *

yes no

If yes, last treatment?

Pregnant or nursing? *

yes no

Brows tinted within the last 2 weeks? *

yes no

On Accutane or acne treatment within the last year? *

yes no

Suffer from autoimmune disorders of any kind? (i.e. MS, RA, Lupus or the like? *

yes no

Do you have oily or severely oily skin? (the hair strokes will appear more blended, solid or not retain at all. Microshading is advised.) *

yes no

Have a thyroid condition and are you taking medication for this condition? (e.g. hypothyroidism, hyperthyroidism, graves' disease, hashi moto’s) *

yes no

Cancer ? *

yes no

If yes, year?

Chemotherapy/Radiation in the last year? *

yes no

Tumors/Growths/Cysts? *

yes no

Difficulty numbing with dental work? *

yes no

Any scars or experienced any head trauma in the brow area? *

yes no

Alopecia? (hair loss due to an autoimmune disease) *

yes no

Suffer from hemophilia? (a rare disorder in which blood doesn’t clot normally causing excessive bleeding after any injury or damage to the skin) *

yes no

Trichotillomania? (compulsive pulling of body hair). Be advised that due to constant pulling, scar tissue is prominent, and pigment will not heal properly. *

yes no

Large pores on your forehead or in the brow area? (pigment will blur/blend in large pores, looking powdered. Microshading is advised.) *

yes no

Taking blood thinners such as : Aspirin, Ibuprofen, alcohol, Coumadin, fish oil, etc. (must be discontinued 1 week prior to the procedure) *

Allergic reaction to any medications such as Lidocaine, Tetracaine, ephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, etc. *

Do you have a MRI scan scheduled in the next 3 months? *

yes no

Do you have a Laser or IPL scheduled in the next 3 months? *

yes no

Have you used any skin care products containing Retin-A, Retinol, glycolic acid oralpha hydroxyl in the last 6 weeks? *

yes no

Allergic reaction to any of the following: antibiotic ointments, metals, latex, rubber, hairdye, paints, nuts, medication, drugs, food, crayons, glycerine? *

yes no

If yes, please specify

Are you going on vacation anywhere that will involve swimming/sun exposure within the next 2 weeks? If yes, proper healing is at risk. *

yes no

Do you have moles/raised areas in or around the brow area? (pigment will not be put into any area that is raised) *

yes no

Do you have extremely thin skin? (transparent/translucent or very vascular) *

yes no

Have you ever had permanent makeup on your eyebrows before? If yes, please submit a photo and wait for approval. *

yes no

Please list medication or vitamins you're currently taking

Submit a picture of your brows (free of makeup) and wait for approval. Photos can also be submitted to: crystaldbeautyy@gmail.com *

____ Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability.

____ 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 will tell all skin care professionals or medical personnel about my permanent makeup procedures, especially if I’m scheduled for an MRI.

____ I accept the responsibility for explaining to you my desire for specific colors, shape, and position for any procedure done today.

____ I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch up session within 6-8 weeks of initial procedure.

____ I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of 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) follow up/touch up after 45 days and within 60 days. After 60 days a fee will apply.

____ There will be no refunds for this elective procedure(s).

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(s) and 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 material given to me and I authorized CRYSTAL DELOATCH, as my technician to perform on my body the Microblading/shading procedure desire today.

Print Name

First Name Last Name

Signature *

Clear

Microblading/Micorshading Consent Form

Client Medical History Form

Please read all statements below. By signing you understand the following completely.