Microblading Consultation & Consent Form

Semi-Permanent Makeup Consultation & Consent
Patient Name*

First NameLast Name
Birth Date*

DayMonthYear
Phone Number

Area CodePhone Number
E-Mail*
example@example.com
Emergency Next of Kin Details

First NameLast Name
Area CodePhone Number
GP Name:*
Full Name
GP Surgery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Health
What is your Skin Type

NormalCombinationOilyDry
Have you taken any of the following in last 2 days?

AsprinIbuprofenCoumadinAlcoholNone of above
Are you pregnant or breastfeeding?

NoYes
Have you received chemotherapy or radiation treatment in the last year?

NoYes
List any medication you have been taking in the last 6 months
Are you allergic to any of the following?

MedicationPaintsCrayonsLanolinVaselineLatex rubberFoodsGlycerinMetalsLidocaineHair dyesAnaestheticsAdrenalineOther
Have you ever had any of the following (Please tick all that apply)

AnaemiaProlonged bleedingHaemophiliaHigh blood pressureDiabetesEpilepsy SeizuresLow blood pressureFainting spells or dizzinessCirculatory problemsLiver diseaseThyroid disturbancesKidney diseaseStomach ulcersTumours, growths, or cystsHIVCancerTuberculosisProsthetic hip or jointStrokePalpitationsHepatitisAlopeciaRecent hair lossTrichotillomaniaGore-Tex implants / silicon injectionsBruise or bleed easilyOther tattoos or fat transfer injectionsSunbed session within last 2 weeksBotox injections within last 4 weeksCollagen injectionsScar easily or problems healingHypertrophic scarsRetin A within 6 monthsChemical or laser peel within last 6 monthsCortisone within last 6 monthsAHA preparations within last 2 weeksKeloid scarsSensitivity to cosmeticsEyebrow tint within last 2 weeks
Please note, if you are undergoing drug / alcohol rehabilitation and having blood / urine samples taken, opting to use numbing products used may show a positive test result.
Patch Testing

The pigment will be tested for sensitivity prior to your procedure taking place. You should inform Hannah immediately if you experience any redness, itching, irritation or swelling due to the pigment test and clean the area of product immediately.

If there is no reaction you can go ahead with the procedure as discussed
Signature

Clear
I confirm that the above medical information l have given is correct and I have NOT experienced any reaction to the pigment test carried out prior to treatment:
General Consent & Procedure Permit
• I hereby authorise Hannah Louise Watkins of Hannah Louise Beauty to perform upon myself the Semi-permanent makeup treatment.

• I am aware that Semi-permanent makeup is a form of cosmetic tattooing.

• l accept responsibility for determining the colour, shape and position of the cosmetic procedure as agreed during the course of my consultation.

• If any unforeseen condition arises in the course of this procedure, calling in her judgement in addition to, or different from those now contemplated, I further request and authorise her to do whatever she deems advisable and necessary in the circumstances.

• I understand that a patch test (allergy test) does not guarantee that I will not have an allergic reaction to the pigment. Hannah cannot accept repsonsibility should a reaction occur.

• If you opt to self-administer numbing product, Hannah cannot accept responsibility if the treatment area does not effectively numb. Each individual is different according to skin type.

• I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade over a period of 1-3 years. Pigments can fade by 30-50% in the first 2 months. Even though the colour has faded the pigment will stay in the skin indefinitely.

• l 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.

• 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 during the first procedure. I understand that this is why I will need to return for a retouch procedure.

• I understand that a retouch procedure will be performed 4-8 weeks after the initial procedure and that after a 12 week period I will be charged an additional fee for any further work. I understand that it is my responsibility to book the appointment at a time convenient for both parties.

• I understand that 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, alcohol intake, smoking, and adhering to 'post procedure' care treatment.

• I understand that upon completion of the procedure there may be swelling and redness of the skin, which will subside between 1-4 days. Swelling can cause the area to look asymmetrical or misshapen. In some cases, bruising may occur.

• Post treatment, I understand that using cosmetics, excessive perspiration, steamy showers and exposure of the sun to the affected area should be avoided.

• l have been advised that the true colour will be seen 4 weeks after each procedure and that the pigment may vary in colour dependent on skin tones, type, age and conditions. I understand that some skins accept pigment more readily than others and no guarantee to an exact effect or colour can be given.

• l agree to follow all 'pre-procedure' and 'post-procedure' instructions as provided and explained to me by Hannah. I confirm that I have received copies of all the relevant aftercare instructions.

• l understand that infections are probable if correct aftercare is not followed.

• I understand that the taking of, or application of prescribed antibiotics may alter the colour of the pigment, cause scarring and/or pigment loss.

• I agree to use only the suggested aftercare creams and apply these as suggested with clean hands and cotton buds.

• l understand that the treated area will scab and flake and picking these scabs will cause scarring to underlying tissue.

• l agree to take anti-herpes medication to minimise outbreaks if I am prone to cold sores (lip treatments only).

• Being of sound mind and body, I accept any and all responsibility myself for any consequence that might arise from my decision to have any permanent cosmetics procedure performed by Hannah.

• For the purpose of documentation, I also consent to the taking of "before and after" photographs of said procedure(s) for record purposes and for use in presentation portfolios.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT AND PROCEDURE PERMIT; THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE AND I ACCEPT FULL RESPONSIBILITY FOR THESE AND OR OTHER COMPLICATIONS WHICH MAY ARISE OR RESULT DURING OR FOLLOWING THE COSMETIC PROCEDURES WHICH IS TO BE PERFORMED AT MY REQUEST ACCORDING TO THIS CONSENT AND PROCEDURE PERMIT.

To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my wellbeing as a direct or indirect result of my decision to have the procedure done at this time. l am over 18 years of age. I am not pregnant. I am not under the influence of drugs or alcohol.
Signature

Clear
I have read an understood the above information and been given a Semi-permanent makeup "Pre Procedure" Info Sheet prior to treatment.
Numbing the treatment area
Semi-permanent makeup is not painful, but can be uncomfortable.

Legislation prevents Hannah from administering a numbing product to make the procedure more comfortable. The Client accepts and agrees that if numbing products are to be used they must be supplied and applied by the Client. Hannah can advise what to purchase.

Allergic reaction can occur from any numbing product. If you do suffer from an allergic reaction you should contact your GP immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptom associated with allergy.

The effectiveness of numbing products can vary from person to person. Each individual is different according to the skin type.
Signature

Clear
I have read and fully understood the above and accept the risks involved with the use of numbing products.
Should be Empty:

Semi-Permanent Makeup Consultation & Consent

Medical Health

General Consent & Procedure Permit

Numbing the treatment area