Microblading/Microshading Consent Form

  • Microblading/Micorshading Consent Form

  • Date*
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  • DOB*
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  •  -

  • Client Medical History Form

  • History of MRSA? (Methicillin-resistant staphylococcus aureus, a bacterium that causes infections in different parts of the body and can be very contagious)*
  • Botox?*
  • Keloid scars?*
  • Diabetes?*
  • Hepatitis (A,B,C,D) ?*
  • Surgical forehead/brow lift?*
  • Easy bleeding?*
  • Facelift?*
  • Easy hyperpigmentation ?*
  • Alcoholism ?*
  • Have any heart conditions or are you on a pacemaker or defibrillator?*
  • Chemical Peel ?*
  • Pregnant or nursing?*
  • Brows tinted within the last 2 weeks?*
  • On Accutane or acne treatment within the last year?*
  • Suffer from autoimmune disorders of any kind? (i.e. MS, RA, Lupus or the like?*
  • Do you have oily or severely oily skin? (the hair strokes will appear more blended, solid or not retain at all. Microshading is advised.)*
  • Have a thyroid condition and are you taking medication for this condition? (e.g. hypothyroidism, hyperthyroidism, graves' disease, hashi moto’s)*
  • Cancer ?*
  • Chemotherapy/Radiation in the last year?*
  • Tumors/Growths/Cysts?*
  • Difficulty numbing with dental work?*
  • Any scars or experienced any head trauma in the brow area?*
  • Alopecia? (hair loss due to an autoimmune disease)*
  • Suffer from hemophilia? (a rare disorder in which blood doesn’t clot normally causing excessive bleeding after any injury or damage to the skin)*
  • Trichotillomania? (compulsive pulling of body hair). Be advised that due to constant pulling, scar tissue is prominent, and pigment will not heal properly.*
  • Large pores on your forehead or in the brow area? (pigment will blur/blend in large pores, looking powdered. Microshading is advised.)*
  • Do you have a MRI scan scheduled in the next 3 months?*
  • Do you have a Laser or IPL scheduled in the next 3 months?*
  • Have you used any skin care products containing Retin-A, Retinol, glycolic acid oralpha hydroxyl in the last 6 weeks?*
  • Allergic reaction to any of the following: antibiotic ointments, metals, latex, rubber, hairdye, paints, nuts, medication, drugs, food, crayons, glycerine?*
  • Are you going on vacation anywhere that will involve swimming/sun exposure within the next 2 weeks? If yes, proper healing is at risk.*
  • Do you have moles/raised areas in or around the brow area? (pigment will not be put into any area that is raised)*
  • Do you have extremely thin skin? (transparent/translucent or very vascular)*
  • Have you ever had permanent makeup on your eyebrows before? If yes, please submit a photo and wait for approval.*

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

  • ____ 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.

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