Brow Consent/ Client History Form

Microblading/ Powder Ombre 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

Area CodePhone 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

Area CodePhone 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, combo or powder ombre brow 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, powder ombré / combo brows and I understand that there might be complications and consequences associated with this procedure, such as: infection, scarring, or inconsistent color. 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 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, combo or powder ombre brow procedure done. Touch ups are highly recommened and I understand they are necessary 90% of the time after my initial appointment (6- 10 weeks depending on the procedure). The cost for touch-up’s after this first procedure are not included.
Signature

Clear

Client health screening Questionnaire

Due to the 2019-2021 outbreak of Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please sign and complete the following to the best of your knowledge, thank you
I blanks (client's name) confirm that I am not experiencing any of the following symptoms of COVID-19 listed below.
Fever, shortness of breath, chills, new loss of taste or smell, new cough, runny nose, muscle pain, unusual/new headache or sore throat within the past 72 hours?

YesNo
I agree to the following:
- I understand the above symptoms and affirm that I, as well as any household members, do not currently have nor have experienced the symptoms listed above within the last 14 days and have not been disgnosed with COVID-19 within the last 30 days.
- In the last 72 hours, I have not been in contact with anyone confirmed to have COVID-19.
- In the last 72 hours, I have not experienced a fever (tempertautre of 100.4 or higher).
- I understand the COVID-19 virus has a long incubation period in which the virus is carried and may not show immediate symptoms & still is highly contagious.
- I understand that due to the of visitis of other clients, the characteristics of the virus, and the characteristics of these services that I am at risk of contracting the virus simply by being in the estblishment.
- To prevent the spread of the contagious virus and to help protect each other, I understand that I must follow the establishments guidelines.
- Reschedule appointment if you are feeling unwell

- No addditonal guests are allowed

- Wearing a mask is required upon arrival and during the entire procedure

- Wash hands upon arrival

- Limit conversation during the procedure

I, knowingly and willingly consent to having microbalding, combo or powder ombre brow service during the pandemic and will not hold Brows by Q liable for the possibility of contrating COVID-19.
Signature

Clear
Date

MonthDayYear
Date
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?
Has diabetes?
Has skin that keloids?
Have any skin conditions? if so please list it
Has epilepsy?
I am aware that the inks being used are not FDA approved.

Microblading/ Powder Ombre Consent Form

Client health screening Questionnaire