Microblading/Micropigmentation Eyebrows

Date

MonthDayYear

Name*

First NameLast Name

Date of Birth*

E-mail Address*

Mobile Phone Number*

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Please read these statements carefully - Permanent cosmetics are a form of tattooing. - Re touch procedures may be required. - A healing period of 4 to 6 weeks is required before any touch-up procedure can be performed. - On rare occasions the pigment may migrate under the skin. - Application of permanent cosmetics can be uncomfortable. - The pigments will fade. - Immediately after the procedure, the pigment can be 30 to 50% darker than the desired result. - There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare. - A negative allergy test result will not guarantee that you will not have an allergic reaction. - Infections can occur if aftercare is not followed. - Allergic reactions to anesthetics can occur. - There may be swelling and redness following the procedure. - You may experience minor bleeding. - If you have a MRI scan within 3 months your permanent cosmetics procedure we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.*

I have read and understand the above statement

Have you taken any of the following in the last 48 hours?*

	Yes	No
Aspirin
Ibuprofen
Coumandin
Alcohol

Have you ever had an allergic reaction to any of the following:*

	Yes	No
Latex Rubber
Vaseline
Metals
Drugs
Paints
Lanolin
Foods
Medication
Glycerine
Lidocaine
Another allergy not listed

If 'yes' or 'another allergy' please provide additional information below

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

YesNo

Please select yes to the following that apply to you;*

	Yes	No
Abnormal Heart Condition
Cold Sores (herpes simplex)
Mitral Valve Prolapse
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Hepatitis
Eye Infection present
Eyelid Surgery
Trichollomania
Gore-Tex Implants/Silicone Injections
Fat Transfer Injections
Botox Injections
Collagen Injections
Hypertrophic Scars
Keloid Scars
Healing Problems
Bruise or Bleed Easily
Acutance within 6 months
Chemical or laser peel within 2 months

1. I hereby authorise Illume Skin Spa Microblading Technician/Micropigmentation 2. Of Illume Skin Spa to perform the microblading/ombre brow treatment upon myself. If any unforeseen condition arises in the course of this procedure(s), calling in their judgement in addition to, or different from those now contemplated, I further request and authorise the technician to do whatever they deems advisable and necessary in the circumstances. 3. I accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. 4. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. 5. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-3 years. 6. I have been informed that the highest standards of hygiene are met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit. 7. 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 this is why I need to return for a retouch procedure. 8. I understand that a retouch procedure will be performed 4-6 weeks after the initial procedure and after 2 months period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties. 9. The result of the procedure is determined by the following: - Medication - Skin Characteristics - (dry, oily, sun-damaged and thickness) - Natural skin undertones - (blending with chosen pigment) - Personal pH balance of skin, which changes from visit to visit - Alcohol intake and smoking - Post procedure care treatment 10. Upon completion of the procedure there may be swelling and redness of the skin, which will subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately following the procedure, however, using cosmetics, excessive perspiration wetting and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. You can however, be assured the procedure, even after only one treatment, looks acceptable and you should feel comfortable appearing in public without additional makeup on the affected area. 11. I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary in colour according to skin tones, skin type, age and skin conditions. I understand that some skins except pigment more readily than others and no guarantee to an exact effect or colour can be given. 12. I am aware that the lip procedures may stimulate any dormant virus such as herpes (cold sores). I am informed that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment. 13. 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 am not under the influence of drugs or alcohol, pregnant or breastfeeding. 14. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. 15. Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by Illume Skin Spa (microblading/Micropigmentation technician) 16. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the microblading/micropigmentation procedure(s)*

I have read and understand the above information

Signature

Cancellation Policy

Medical Information

General Consent & Procedure Permit