Microblading Consent Form
Client Details
Date
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Month
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Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Email
example@example.com
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Medical History Inquiry
Have you had or currently have any of the following
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?
Please list down any medications you are taking
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Contact in case of Emergency
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
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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 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 procedure done. The cost for touch-up’s after this first procedure are not included.
BROW AFTERCARE
Wash brows morning and night for 10 days with unscented dial soap only.
After following your cleansing aftercare process, apply healing lotion, morning, afternoon and night for 10 days to ensure optimal retention.
Rice grain size amount will cover both brows.
NO makeup on them for 10 days
NO direct sunlight for 10 days
NO picking or rubbing scabs
NO sweating
NO submerging in water, pools, etc.
Use sunscreen on them once they're healed
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