Name
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First Name
Last Name
E-mail Address
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Mobile Phone Number
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Landline Phone Number (if applicable)
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Date of Birth
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Please read these statements carefully - Permanent cosmetics are a form of tattooing. - Re touch procedures may be required. - A healing period of 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 anaesthetics 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.
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I have read and understand the above statement
Microblading Treatment Required
Please choose the type of treatment required
Please select the option the best describes the microblading treatment required
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Fully Reconstruct
Define Existing Brows
Make Existing Brow Bigger
Medical Information
Name of Doctor
Surgery Name
*
Surgery Phone Number
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Surgery Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list all the medication taken within the last 6 months
Have you taken any of the following in the last 48 hours?
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Yes
No
Aspirin
Ibuprofen
Coumandin
Alcohol
Have you ever had an allergic reaction to any of the following:
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Yes
No
Anaesthetics
Adrenaline
Latex Rubber
Vaseline
Crayons
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?
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Yes
No
Please select yes to the following that apply to you;
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Yes
No
Abnormal Heart Condition
Cold Sores (herpes simplex)
Mitral Valve Prolapse
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Palpitations
Hepatitis
Cataracts
Blurred Vision
Dry Eyes
Eye Infection present
Alopecia
Recent Hair Loss
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Gore-Tex Implants/Silicone Injections
Fat Transfer Injections
Botox Injections
Collagen Injections
Hypertrophic Scars
Keloid Scars
Scar Easily
Healing Problems
Bruise or Bleed Easily
Sensitivity to Cosmetics
Use of Sun bed
Acutance within 6 months
Cortisone within 6 months
Chemical or laser peel within 6 months
Retin A within 6 months
AHA preparations within last 2 weeks
General Consent & Procedure Permit
I hereby authorize the technician at Flawless Spa Retreat of Distinction 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 authorize the technician to do whatever they deems advisable and necessary in the circumstances. I accept responsibility for determining the color, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I confirm I have completed a patch test for this procedure, within 6 months of the treatment date. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-2 years. 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 desirable results and that 100% success cannot be guaranteed. I understand this is why I need to return for a retouch procedure. I understand that a retouch procedure will be performed 1-3 months after the initial procedure and after a 3-month period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties. 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 . 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. I have been advised that the true color will be seen 1 month after each procedure, and that the pigment may vary in color 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 color can be given. 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. 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. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. 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 a technician at Flawless Spa Retreat of Distinction. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the microblading procedure(s)
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I have read and understand the above information
Topical Anaesthetic Form
Allergic Reaction– Allergic reaction can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptom associated with allergy. Numbness - We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is totally numb while others say they experience some discomfort. Procedure – For all procedures a cream or gel topical anaesthetic is used. These products are perfectly safe, and can be purchased over the counter from any chemist. The anaesthetic is placed over the treatment area for between twenty to thirty minutes then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between one and four days. You should always follow your post procedure instructions.
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I have read and understand the above information
Signature
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Date
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Month
-
Day
Year
Date
Authorized Use Only
Skin Type
Pigment Colour
Consultation Date:
Treatment Date:
Top-Up Date:
Location
Treatment Price
Top Up Price
Date Completed
Skin patch test
Pre instructions
After Care instructions
Before photos
After photos
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