Microblading Consent Form

Microblading Consent Form
Client Details
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com

Contact in case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

CONSENT

I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and I consent to receiving the microblading procedure. I have been informed and it was explained to me the general nature of cosmetic tattooing as well as the specific procedure to be performed.

I have been informed of the possible risks and consequences of microblading and I understand that there might be complications and consequences associated with this procedure, such as: infection, scarring, or inconsistent color.

I understand that with microblading, the skin is broken by needles and may cause the transmission of blood-borne pathogens and related diseases. Risks include contamination and the transmission of blood-borne pathogens such as hepatitis B and HIV among other risks.

I understand that this cosmetic procedure is not fully permanent and might result to fading in time. I have likewise received and will strictly adhere to procedural instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my responsibility.

I understand that the ink for microblading currently is not approved for FDA

I have been advised to do a patch test to identify any allergic reaction to any medicine or anesthetics. Should I waive for the test, I release the technician from liability if I develop an allergic reaction to any of the procedure.

I acknowledge that some changes might not be corrected in case I undergo other laser hair removal, plastic surgery or other procedures.

I understand that photographs taken for comparison of the before and after procedure are part of the said procedure.

I accept full responsibility for the decision to have this microblading procedure done. The cost for touch-up’s after this first procedure are not included.
Signature

Clear
Should be Empty:

	Yes	No
Currently Pregnant
Currently Breastfeeding
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)
Had undergone Botox treatment
Has or any family history of Diabetes
Has Hepatitis A B C D
Had Forehead/Brow Lift
Had Facelift Surgery
History of Alcoholism
Has a Heart Condition
Had a Brow Lash Tinting
Has Autoimmune disorder
Has Oily Skin
Has, had, or any family history of having Cancer
Had undergone Chemotherapy/ Radiation
Taking or have taken acne treatments in the past 3 months
Had a Tan treatment
Difficulty numbing with dental work
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc
Allergic reaction to any medications
Allergies to metals, food, etc,
Any diseases other than listed here
Do you use facial care treatments?