Cosmetic Tattoo/Microblading or Powder Brow Consent Form

Cosmetic Tattoo/Microblading Questionnaire Form

(This is a legally owned document, Please do not reproduce, copyright Jealousy Studios, JMP Ventures LLC)
Your Information
Full Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Phone Number

Area code +44Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Above is a pre drawn selection of styles Available please select which you like ?
Are you interested in any other types of cosmetic tattooing or services that we offer?
What is your skin type? (required)
What's your preferred makeup style? (required)
Have you previously had semi permanent make up done ? And when if yes, how long ago and what type was it (machine or microblade)
FEMALE ONLY: Pregnancy or Nursing?
Anxiety Disorder, Bi-Polar, or Clinical Depression?
On Medication Currently?
If yes please list (this is to verify you are a candidate some medication is a contraindication)
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Any known allergies ?
Powder Brows/Microshading/Microblading can heal patchy and different color from what has been used , this is out of our control and we cannot guarantee any results from microblading or how long they will last are you happy to accept this risk ?
Above is showing how we make sure your eyebrows are drawn on perfectly to suit your face . We use this guide as microblading is not a 1 shape fits all . Every person brows are tailored to suit there face shape . When we draw on your brows prepare for them to not look like they will when complete . When pre drawing we use a combination of of black and white pencils to mark exactly we're is needed to tattoo
Please submit picture of your full face without makeup (front view)

Browse Files

Cancelof
Please submit picture of your full face without makeup (side view)

Browse Files

Cancelof
Client Name
Signed Date

MonthDayYear
Date
Client Signature
Signed Date

MonthDayYear
Date

Cosmetic Tattoo/Microblading Questionnaire Form

Your Information