Microblading/Ombre Treatment Form

Name

First NameLast Name

E-mail Address

Phone Number

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Occupation

Date of Birth

Are you over the age of 18?

Are you pregnant or nursing?

Please read these statements carefully - Permanent cosmetics are a form of tattooing. - Re touch procedures may be required. - A healing period of 4 to 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. -Results vary from client to client and depend on each individuals health, lifestyle, and skin type. - 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. - Topical anesthetic, nickel in tattoo needles or certain pigments may trigger allergic reactions in rare occasions. -A negative allergy test result will not guarantee that you will not have an allergic reaction. - Infections can occur if aftercare is not followed. - There may be swelling and redness following the procedure. - You may experience minor bleeding. - If you have a MRI scan within 3 months of your permanent cosmetics procedure we recommend that you discuss this with your doctor. Every tool used for your procedure has been pre-sterilized and is disposable and disposed of after use. Every measure is taken to prevent cross-contamination. Wound infections are possible during the healing process if you do not strictly adhere to your recommended aftercare instructions. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.

Please select the option the best describes the microblading treatment requested

Other

Name of Doctor

Previous Surgeries

Please list all medications currently taking or taken within the last 6 months

Recent health history.

Rows	Yes	No
Aspirin or Ibuprofen in the last 48 hours
Coumandin in the last 48 hours
Alcohol in the last 48 hours
Have you ever had cold sores or fever blisters?
Ever had permanent makeup before?
Do you have eczema, rosacea, dermatitis, or alopecia?
Do you routinely use Retin-A, glycolic, or other exfoliation products?
Do you wear contact lenses?
If you have had permanent cosmetics or tattoos, have you had any problems with healing after they were applied?
Do you have issues healing?
Are you sensitive or allergic to hand creams or body lotions?
Do you scar easily from minor skin injuries?
Have you had Botox injections in the last 2 weeks?
Do you have glaucoma or any other eye diseases?
Do you bleed excessively from minor cuts?
Do you bruise easily?
Do you consume aspirin daily?
Are you using any eyebrow or eyelash growth serums?
Do you have a history of stroke or heart attack?
Are you now, or have you ever been on the acne treatment accutane?
Do you have a history of skin sensitivities?
Do you use tobacco?
Do you have any medical condition that has resulted in medical professionals requiring you to pre-medicate prior to invasive procedures?
Do you have any auto-immune disorders?
Do you intentionally tan your face- direct sun or tanning bed?
Do you hypo pigment (lack of pigment)
Do you hyper pigment (develop dark spots on the skin from wounds or sun)

Have you ever had an allergic reaction to any of the following:

Rows	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?

Please select yes to the following that apply to you;

Rows	Yes	No
Abnormal Heart Condition
Cold Sores (herpes simplex)
Mitral Valve Prolapse
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Hemophilia
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
Collagen Injections
Hypertrophic Scars
Keloid Scars
Scar Easily
Healing Problems
Bruise or Bleed Easily
Sensitivity to Cosmetics
Use of Sun bed
Accutane 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
Botox within the last 2 weeks

1) I hereby authorize Hannah Johnson of Peony House Beauty LLC to perform the permanent cosmetics/microblading 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 authorise the technician to do whatever they deems advisable and necessary in the circumstances. 2) I accept responsibility for determining the color, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. 3) I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I confirm I am aware that a patch test for this procedure doesn’t guarantee that I will not have an adverse reaction to the procedure 4) I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-3 years. 5) 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. 6) 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 6-8 weeks following initial procedure. 7) I understand that a retouch procedure will be performed 6-8 weeks after the initial procedure and after a three 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. 8) 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, acohol intake and smoking, & Post procedure care treatment. 9) 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. 10) 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 accept pigment more readily than others and no guarantee to an exact effect or color can be given. 11) I am aware that the lip procedures may stimulate any dormant virus such as herpes (cold sores). I am also aware that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment. 12) 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, and I am not pregnant or breastfeeding. 13) I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. 14) Being of sound mind and body, I hereby release Hannah Johnson and/or Peony House Beauty LLC of 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 Hannah Johnson. 15) For the purpose of documentation and advertisement/social media usage, I also consent to the taking of “before” and “after” photographs of the permanent cosmetic procedure(s)

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.

I am aware that the microblading procedure will not change my natural brow hair color and/or brow hair growth and that regular maintenance of my natural brow hair (waxing, tinting, etc.) will be likely to maintain the desired shape/color.

I understand and agree that this is a beauty service and there will be no refunds.

This agreement will remain in effect for this procedure, and all future procedures conducted by my professional or any other professional conducting business at Peony House Beauty.

Payment as follows…total service cost is 615.00. 110 paid at consultation to book initial appointment, 395 due at initial appointment, and 110 balance at 6-8 week touch up appointment (regardless if you no show this appointment, the final 110 will still be charged to card on file)

Signature

Date

Skin Type

Pigment Colour

Consultation Date:

Treatment Date:

Touch-Up Date:

Location

Treatment Price

Rows	Date Completed
Skin patch test
Pre instructions
After Care instructions
Before photos
After photos

Microblading Treatment Required

Medical Information

General Consent & Procedure Permit

Topical Anaesthetic Form

Authorised Use Only