CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING/PMU

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CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING/PMU

30 mins have been set aside for you to read and fill out this form. Please take your time in filling this form, and read all of it in its entirety. You will not be seen sooner if you finish quickly, its very important you take your time and read and understand this form. This entire process can take up to two hours. Thank you for your patience.
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If any of these conditions apply to you, we may do the procedure ONLY with a Doctor’s letter.
- CERTAIN BLOOD THINNING MEDICATIONS
- LOW/ HIGH BLOOD PRESSURE
- HEART PROBLEMS/BLOOD PROBLEMS
- DIABETES TYPE 2
- HAEMOPHILIA
- EPILEPSY
- CANCER/AUTO-IMMUNE DISEASE
- ALOPECIA
If any of these conditions apply to you, we can NOT do the procedure AND you may forfeit the deposit as this is in your pre care email.
- UNDER THE INFLUENCE OF ALCOHOL/DRUGS
- EXISTING OR PRIOR WORK/TATTOOS ON THE BROW AREA THAT WERENT CLEARED PRIOR THRU EMAIL OR TEXT
- UNDER THE AGE OF 18 without consent
- LIVER DISEASE
- HIV/HEPATITIS
- SERIOUS HEART DISORDERS
- BLOOD INFECTIONS
- AUTOIMMUNE DISEASE/LUPUS
- COVID-19 or SICK
- PREGNANCY
- CANCER
- Currently on Accutane or other strong retinoids (must wait until 4 weeks after treatment ends)
- If any RASH, skin diseases symptoms or irritation appears on the area.
- You've recently had Botox or Disport treatment (must wait 2 weeks)
- If you have a sunburn.
- After waxing (must wait 3 days)
- After chemical peels (must wait two weeks)
What is your main concern/issue relating the area to be treated?*
What specifically would you like to improve? *
I have fully understood the information provided above. I can confirm that all of the information provided by me is correct and truthful. I have consulted my Doctor or Medical Provider and can have the procedure.
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DISCLOSURE AND RELEASE FORM FOR MICROBLADING/PMU PROCEDURE
I understand each statement completely: (please check each statement)

Microblading can last 3-18 months depending on how my skin reacts to the procedure. There may be fading and/or discoloration due to my skin type or lifestyle. The result may not be what I expected to receive. I understand this is a semi permanent make up procedure that may take numerous touchups that I am responsible for to get my desired results. My artist will do the best humanly possible to their ability to achieve the desired result. My skin and aftercare protocol is also what can determine results and my next retouch may be as soon as 3 months but usually is yearly .
By checking the boxes, you confirm that you agree with the following statements:*

It is my responsibility to book a retouch within the 6-12 week timeframe for microblading and 3-6 months for shading. PMU is a TWO-STEP process and I must come in to perfect the session at the retouch. This is my responsibility to pay (not included)There is no guarantee or warranty made to me as a result of this procedure and the final result cannot be promised. Any spacing, or faded strokes are part of the process and I must give a chance for the strokes to heal and be detailed at the retouch that is not included.There are NO refunds for this procedure, as results vary per individual.There may be risks and hazards related to performing this procedure.There may be discomfort and pain during the procedure, even though we will numb you as much as we can.There is a possibility of bleeding, swelling, redness and allergic reactions to pigment in the future. Redness and swelling can last up to 6 weeks, depending on your skin type.Microblading is considered semi-permanent and can/will fade over time.Microblading, though semi-permanent, may last permanently and may not fade.Surgical/laser procedures may be required to remove pigment from skin. These procedures may cause scarring and damage to the skin.I will notify my DR if an MRI is to be performed within 6 monthsFinal results cannot be determined until brows are fully healed (6 weeks) after procedure. Any issues or concerns will be addressed at the retouch and is not included in the original appointment price.I have received post care instructions and will follow them to ensure results are satisfactory. I must wait 6 weeks to see true results.I am NOT pregnant.I am NOT under the influence of drugs/and or alcohol or any other mind altering substance.I fully understand the plan in place for my procedure that my artist has explained to achieve my desired results. I understand the procedure, the results, the retouch process, and the aftercare and give permission to my technician to perform the service with all the information that has been provided.I am fully aware of the risks and release Leslie Mendoza, Prime Boudoir and The Brow Guru Corp from all liability in relation to the microblading/pmu procedure.I have truthfully and willingly filled out the consent forms and have informed my technician of all the medications I have/am taking.I have REFUSED the patch test for allergies to Lidocaine/epinephrine if I’m allergic to lidocaine or epinephrine (numbing agentsI release The Brow Guru corp and PRIME BOUDOIR TECHNICIAN and its subsidiaries of all above claims of injury, seen or unseen that may occur as a result of this procedure.
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GENERAL CONSENT AND PROCEDURE PERMITFORM
If any unforeseen condition arises in the course of my microblading/PMU procedure, I authorize my therapist to use their professional judgement to decide on what he/she feels necessary in the given circumstances. I accept the responsibility for determining the color, shape and position of the microblading/PMU procedure as mutually agreed during the consultation part of my appointment.

I understand that an allergy test does not guarantee that I will not develop an allergic reaction to the pigment in the future.

I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-3 years. Even once the color will fade, pigment itself may stay in the skin indefinitely.

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.

I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results, and that 100% success cannot be guaranteed during the first procedure. I understand that I must return for a repeated perfecting procedure at least once within 6-20 weeks at an extra cost.

The result of the procedure is determined by the following; medication, skin type, lifestyle, personal pH balance of your skin, alcohol intake and smoking, and most importantly post procedure after care. Upon completion of the procedure there might be swelling and redness of the skin, which should subside between 1-4 days. In some rare cases, bruising may occur.

You may resume your normal activities following the procedure, however, direct water, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed (14 days minimum). Your technician will explain based on your service and skin type. Please see the after care card for more details. Healed results will be seen after 6 weeks. There will be swelling, uneven-ness due to swelling, and some strokes or color may not stay due to many reasons, and a second session is required to acheive the desired results.

I have been advised that the true color will be seen at least 6 weeks after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be promised. 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 agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the therapist. I can confirm that I have received a copy of after care details. Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequences that might stem from my decision to have any permanent cosmetics procedure performed by the therapist.
Technician Name:
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For the purpose of documentation, record and use in portfolio, I also consent to the taking of “before” and “after” photographs of my procedure that may or may not be used on many platforms across social media, our website and for marketing use. You may be recorded and video taped.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND ACCEPT FULL RESPONSIBILITY FOR THESE AND OR OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE MICROBLADING/PMU PROCEDURE. THE TREATMENT IS PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT, PRE-PROCEDURE FORM AND POST PROCEDURE GUIDELINES. I HEREBY AUTHORIZE TECHNICIAN TO PERFORM THE MICROBLADING PROCEDURE ON ME AT PRIME BOUDOIR.
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MICROBLADING/PMU PRE PROCEDURE ADVICE
Microblading/PMU procedures normally require multiple treatment sessions. For premium results, clients will be required to return for at least one retouch appointment within 6-12 weeks after initial appointment.

Please be prepared that color intensity will be significantly darker and sharper immediately after the procedure. This will usually reduce by 30%-50% after healed, and I am prepared to be patient. Swelling may distort what the results look like immediately, and may last up to a week.

Although numbing cream is used during the procedure, some discomfort can be felt by sensitive clients.

Delicate or sensitive skin may be red and/ or swollen after the procedure.

Please do not drink alcohol the night before treatment.

Any brow shaping using waxing should be performed at least 48hrs before the treatment.

Electrolysis treatment should be undergone no less than 5 days before the treatment.

AHA preparations should be undergone no less than 2 weeks before the treatment.

Chemical, laser peel retin A should not be performed 6 weeks before the procedure.

TOPICAL ANESTHETIC ADVICE

Allergic reaction: This can occur from any anesthetics used during procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction. We use 5% lidocaine, epinephrine and tetracaine. If you are allergic to any topical numbing, please let us know immediately.

Numbness: We cannot accept responsibility if the area to be treated does not respond to the numbing cream. Each individual is different according to skin type.

Procedure: For microblading/PMU procedures a topical numbing cream/gel is used. It will be removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic you can expect to experience some redness/ swelling that can last 1 - 4 days. It is very important for you to follow your post procedure advice/ after care for ultimate results.

I have read and fully understood the above information provided and any risks involved with the use of topical anesthetic and I therefore consent to the use of the anesthetic for the microblading PMU procedure. I agree to follow pre-procedure advice closely.
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CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING/PMU

DISCLOSURE AND RELEASE FORM FOR MICROBLADING/PMU PROCEDURE

GENERAL CONSENT AND PROCEDURE PERMITFORM

MICROBLADING/PMU PRE PROCEDURE ADVICE