Radiant Skin & Brows Microblading Information and Consent form

Radiant Skin and Brows - Permit No. 117130

Microblading Information and Consent Form
Name*
Date of birth*

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Date
Address*

Street Address

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Email*
example@example.com
Pre-treatment Instructions
- Client must be off Accutane or other prescribed acne medications for at least 6 months before procedure.
- Client must not use brow hair growth serums two weeks before or one month after procedure.
- 24 hours prior to the procedure, please refrain from the following:
  - Alcohol and Drugs
  - Ibuprofen
  - Aleve
  - Energy Drinks
  - Coffee
- 5 days prior to the procedure, please refrain from the following:
  - Vitamin E
  - Fish Oil
  - aspirin and other blood thinners
- 4 weeks prior to the procedure, please refrain from using any topical retinoids (retin A, tretinoin, retinol, adapalene, etc)
- All of the above products may cause excessive bleeding and sensitivity and could negatively affect the longevity of your semi permanent makeup application.
- No alcohol or caffeinated drinks on the day before and day of the procedure in order to minimize bleeding and sensitivity during the procedure.
- Any brow tinting should be done 1 week prior to treatment.
- Botox and other injections should be performed at least 14 days before or 14 days after the treatment.
- Microdermabrasions, chemical peels, mesotherapy, or other intense treatments should be performed at least 4 weeks before or after treatment.
- Any brow hair removal (i.e. waxing, plucking, threading, electrolysis) should bedone at least 1 week before the treatment.
- Avoid excessive sun exposure at least 2 weeks before appointment. Please wear sunscreen to avoid excessive tanning or burning so skin is in good condition for appointment.
- Please contact me to reschedule your appointment if you have sun burn / acne in or near brows, or active cold sores anywhere on the face. Microblading cannot be performed in these conditions.
By signing this form I, , am acknowledging that I have read and understand these statements.*
Aftercare Instructions
Hours 1-3
- Pat brows with clean tissue to remove any lymph or blood as needed.
Days 1-10
- Gently wash using clean fingertips with a gentle, fragrance-free soap and water morning and night (no washcloth).
- PAT dry with a clean towel.
- Apply a rice grain amount of provided ointment with a clean q-tip as needed.
- Do not over-apply ointment to allow brows to breathe.
AVOID the following while brows are healing:
- Avoid getting brows wet while showering and shorten showers to avoid excess steam. Apply a layer of ointment on brows before showering to provide a barrier.
- Do not use makeup or any other products on your brows besides what has been provided in your aftercare kit until brows are fully healed (~10-14 days).
- Avoid excessive sweating or steam (saunas, gym, sports, jacuzzis, hot showers, etc).
- Avoid sun exposure. Wear a hat when outside until brows are healed. Use sunscreen once brows are healed.
- Do not touch your brows unless your hands are freshly washed to avoid infection.
- Do not pick, scratch or itch brows. Picking at scabs could pull out pigment.
- Avoid sleeping on your face while brows are healing and use a clean pillowcase. Silk/satin pillowcase is HIGHLY recommended.
If you are experiencing excessive redness, swelling, tenderness, elevated temperature, or purulent drainage from the procedure site, please contact your physician as this could indicate infection. If physician care is required, please notify me of the problem and resolution provided by the physician.
By signing this form I, , am acknowledging that I have read and understand these statements.*
Type name here
Healing Expectations
First 2 days: The color will be a little dark. Slight swelling, thickness, and/or redness for 1-2 days following the procedure.

After about 7-10 days: The color will appear to be very light

After 14-28 days: The color will resolve itself to its appropriate shade

General Healing Expections
- The color will appear softer once your brows are completely healed. It is normal to lose approximately 1/3 of the color during the healing process.
- Complete healing takes 30 days.
- Your touch up appointment (after 6-10 weeks) will perfect your look adding hair strokes if needed, and going over any faded strokes.
- Your brows will appear approximately 20% to 25% darker and wider than they will be when completely healed.
- Natural exfoliation will cause the excess pigment surrounding the eyebrow procedure to flake away and narrow the width of your brows.
- Don't be concerned that your eyebrows will initially appear darker and heavier in size than you desire, this is all part of the healing process.
By signing this form I, , am acknowledging that I have read and understand these statements.*
Type name here
Possible Risks and Hazards
Pain: There may be some pain even after the topical anesthetic has been used. Anesthetics work better on some people than others.

Asymmetry: Every effort will be made to avoid asymmetry, but our faces are not perfectly symmetrical. Adjustments may be needed in the followup session.

Anesthetics: Topical anesthetics are used to numb the microbladed area. Lidocaine, Tetracaine, and Epinephrine are among the ingredients in these creams. Please notify the artist of any allergies to these ingredients or any others.

Uneven Pigmentation: This can result from poor healing, infection, bleeding or many other causes. Your followup appointment will help correct any unevenness.

Poor Pigment Retention: There are many factors that affect pigment retention, including client following pre and after care instructions and client's immune system and hormones. Fading always occurs to some degree, and touchups are meant to build the pigment up to the desired saturation. However, poor pigment retention may still occur, as it is unpredictable how the skin will take the pigment.

Excessive Swelling or Bruising: Some people swell or bruise more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don't swell or bruise at all.

Infection: infection is very unusual but possible. The areas treated must be kept clean and only freshly washed hands should touch the areas.

Allergic Reaction: There is a possibility of an allergic reaction to the pigments or other materials used. Please notify your artist of any metal allergies. 5-7 day patch test is available if you are concerned about allergic reaction.

MRI: Because pigments used in permanent cosmetic procedures contain inert oxides, a low level magnet may be required if you need to be scanned by an MRI machine. You must inform your technician of any tattoos or permanent cosmetics.
By signing this form I, , am acknowledging that I have read and understand these statements.*
Type name here
Confidential Medical Profile
To avoid unforeseen complications, please check the box for yes or leave it blank for no to answer the following questions

Previous Permanent Make Up? If yes when?Are you under the age of 18?Have you had Botox or injectables? If yes when?Are you currently pregnant or nursing?Epilepsy/Seizures of any kind?Any Autoimmune/Thyroid Disorders?Currently or have you had cancer? If yes, when?Are you currently undergoing radiation or chemotherapy?Do you have hepatitis?Do you have diabetes?Do you have HIV?Do you have any heart conditions?Do you have alopecia?Do you have keloid or hypertrophy scars?Do you have Eczema or Psoriasis on any part of your face?Have you undergone Accutane treatment? If yes, when?Have you had a chemical or laser peel? If yes, when?Have you taken aspirin or blood thinning medication in the last 7 days?Do you take antidepressants or mood altering medication?Do you have any problems with healing?Do you get fever blisters or cold sores?Are you currently using Retin-A or Alpha Hydroxyl skincare products?Have you had caffeine products in the last 24 hours?Are you taking any medication, including immunosuppressive, such as anti-inflammatory steroids?Are you allergic to topical antibiotic preparation? e.g. Polysporin, Bacitracin, Neosporin, orDo you have a history of skin diseases or remarkable skin sensitivities?Are you presently taking Vitamins A, E or fish oil in any form?Are you required to take antibiotics during dental or invasive medical procedures?Are you allergic to any food, metals, etc.?Any tendency to bleed excessively from minor cuts?Do you smoke cigarettes/use nicotine?Do you tan often (sun or tanning bed)?Other
Please list any explanations if you answered yes to the above questions. List any medications and allergies. List doctors names and numbers.
By signing this form I, , am acknowledging that I have read and understand these statements and that all information provided is accurate.*
Type name here
Photo Release Form
Before and after photos are required for insurance purposes and are mandatory, but I would also like your permission to use these photos/videos for promotional or educational purposes.
YES, feel free to use my photos/videosNO, I'd prefer you didn't use them
Consent Form
Please read and initial all lines:
I certify to not be under the influence of drugs or alcohol at my appointment.*
I certify that I am not pregnant or breastfeeding. *
I have voluntarily elected to undergo this procedure after the nature and purpose have been explained to me, along with the risks and hazards involved.*
Aftercare instructions have been explained to me and a written copy will be given to me to retain in my possession, which I will follow to the best of my ability. If I have questions I will call or text you.*
I understand that Retinoids, Alpha Hydroxy Acids must not be on the treated areas. They will alter the color.*
I understand that sun, tanning beds, pools, some skincare products and medications can affect my permanent makeup.*
I accept the responsibility for explaining to you my desires for specific colors, shape, and position for any procedure done today.*
I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control and I will need to maintain the color with future applications and a touch up session within 10 weeks.*
I acknowledge that the proposed procedure(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures such as: infection, misplaced pigment, poor color retention and hyper-pigmentation. And that, because of this, results cannot be guaranteed.*
I have been quoted the cost of today’s appointment which includes one (1) touch up after 6 weeks and within 10 weeks. After 10 weeks a fee will apply and there will be no refunds for this elective procedure(s). I understand there are no refunds, and no exceptions.*
I understand and agree to the following cancellation/reschedule policy: The retainer fee I have paid to book the appointment is nonrefundable, but transferable ONE time if reschedule is made at least 24 hours before appointment and within 3 months of original appointment. If I am more than 15 minutes late, my appointment will be cancelled and I will need to reschedule with a new retainer fee.*
By signing this form I, ,certify that I have read the contents of this form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me and I authorize Rachel Farmer as my microblading/shading artist to perform on my body the cosmetic eyebrow procedure desired today.*
Type name here
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Radiant Skin and Brows - Permit No. 117130

Pre-treatment Instructions

Aftercare Instructions

Healing Expectations

Possible Risks and Hazards

Confidential Medical Profile

Photo Release Form

Consent Form