New Client Microblading Consultation Record

Microblading Consultation Record
Appointment Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Age?*
Preferred Contact Method?*
Please read carefully – and sign where indicated. Ensure all you have read and understood all information and you accept the terms detailed in this form.
- I have chosen a cosmetic procedure that is not medically necessary.
- The procedure cannot take place if you are pregnant or breastfeeding. Three months post either applies.
- In the first 7 days eyebrows will be up to 40% darker and 10-15% thicker than the final result.
- The shape created is determined according to facial proportions, and symmetry is determined digitally with closed eyes to find the start, arch and end points.
- Microblading/shading is an art process not an exact science, your technician cannot guarantee an exact colour due to how pigments heal differently in all individuals’. The final colour will depend on natural skin pigment. The chosen colour will appear darker immediately after treatment. The darker colour will exfoliate and lighten within 7-14 day
- Oily skin requires more maintenance to retain colour and results.
- You will be required to return for a top treatment between 4-6 after the initial treatment which will deem your treatment complete.
- In some cases a third touch up may be required due to your skin type or lifestyle this is an extra cost of £50.
- A retouch will be required periodically to keep the procedure looking fresh. A minimum and maximum duration of the result cannot be determined with certainty and no warranty can be given for treatment. Usually between 9-18 months.
- Due to each skin type being different the permanence of the treatment cannot be guaranteed.
- Pigments used in microblading can contain iron oxides. It is essential you inform your radiologists before a CT or MRI Scan
- I agree to strictly follow the aftercare instructions given to me. Failing to do so may result in poor results, infections, scarring or addition treatments needed.
- Skin altering treatments such as peels, plastic surgery, implants, injectables, botox may alter the look of the micropigmentation.
Terms and Conditions

Due to Carly running to a strict time schedule, limited parking spaces at the salon and having to clean in between clients (due to COVID) please do not arrive early for your appointment.

Your appointments are very important to me. Your appointment is reserved especially for you and, while I understand that sometimes schedule adjustments are necessary, I respectfully request at least 48 hours’ notice for cancellations.

Deposits are non-refundable and can only be transferred to an alternative date on one occasion and as long as in excess of 48hrs notice has been provided.

Please understand that when you forget or cancel your appointment without giving enough notice, I miss the opportunity to fill that appointment time (mainly due to the nature of microblading and the Pre-care Advice rules that need to be followed) and clients on my waiting list miss the opportunity to receive services, in addition to this I still have to pay salon rent, childcare plus other business expenses.

You do automatically receive an appointment reminder 24 hours in advance because I know how easy it is to forget an appointment you booked months ago.

CANCELLATION FEES

Since the services are reserved for you personally, a cancellation fee (your deposit) will apply if you fail to give at least 48 hours’ notice that you will not be able to make your appointment (this does also apply should you have COVID).

Cancellations should be made by phone 07525267754, via message on Carly Joan Browns and Beauty Facebook page, or alternatively email to carlyjoanbrowsandbeauty@gmail.com

Payments on the day can be made by cash or by card machine

You are signing to confirm that you have read the pre care advice, T&C's and are happy to proceed with treatment.
Signature*

Clear
Patch Test / Waiver - Please tick A or B
A. I understand that a skin test can determine whether I will suffer a reaction to the products used, but that it is inconclusive as to whether I will have a reaction at any time in the future. I waiver my option to an allergy test and release the technician for any liability if a reaction occurs and wish to proceed with treatment.
B. I have undergone a patch test at least 48hrs prior to my initial treatment and I therefore release the technician from any liability related to a reaction to the applied pigments or any other products used during or after treatment or at a later date.
Date of Patch Test?*

DayMonthYear
Date
Signature*

Clear
Covid-19 Rules
I agree not to come to the salon if I have experienced any symptoms of COVID-19 within the last 48 hours.

To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to wear a mask at all times, unless I am exempt.

I’m willing to take a temperature check during my visit to the salon before the services are started.
Signature*

Clear
Consent
I understand that my Phibrows artist will be in direct contact with me in relation to the treatment. This treatment involves the use of disposable sterile blades, and all equipment used is a single use or sterilised before treatment, all surfaces involved with the process are protected and gloves will be worn at all times during the treatment by my technician.

I hereby consent to Microblading and or shading. My technician has explained the terms and conditions of this treatment and I fully understood those. I hereby consent to the technician who is a trained Phibrows Artist, to carry out the treatment as requested by me on this consent and treatment agreement.
Signature*

Clear
Photographic Consent
I consent to photographs being taken before, during and after treatment. I agree to these being stored with my consent?*

YesNo
I consent to photographs being taken before, during and after treatment. I agree to these being used for promotional purposes on social media?*

YesNo
To Comply with the Tattooing Act Please Answer Yes or No
Are you over the age of 18?*

YesNo
Are you pregnant or Breast feeding?*

YesNo
Are you under the influence of drugs or alcohol?*

YesNo
Have you had any form semi-permanent make up done before?*

YesNo
If YES how long ago was this?
Which clinic?
Were you happy with the result?

YesNo
If NO please explain why?

Medical Disclosure*

	Yes	No
Do you feel fit and well and able to have Microblading today?
Do you have any allergies or have you experienced any reactions to any medicines, anaesthetics etc?
Are you on any medications?
Are you planning on having any injectables, fillers or peels in the next 10 weeks?
Are you planning on going on holiday into direct sunlight imminently?
Do you have epilepsy?
Do you suffer from any infectious diseases?
Do you have high or low blood pressure?
Do you have diabetes? If yes what type?
Do you have any respiratory problems?
Do you have any problems with general healing?
Do you have HIV or AIDs?
Do you have Hepatitis?
Do you have Haemophilia?
Do you have eczema/psoriasis in the eyebrow area?
Do you have any keloid scars?
Do you use any creams or medications to thin the skin?
Have you had treatment for cancer in the last 12 months?
Any cardiovascular issues?

If the answer was yes to medication please list and specify what for?
If you suffer from any infectious diseases please list below?
Notes to Discuss
Please tell us what your dream brows would look like?*
Do you want your brows to look like make-up or hairs?*
Any other comments?
I understand the importance of giving accurate and complete medical history. I understand that withholding information may be detrimental to my health and safety during or after my treatment. I understand that if there is any change in my medical history that it is my responsibility to inform my technician before any treatment.
Signature of Client*

Clear
Name*

First NameLast Name
Date:*
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Microblading Consultation Record

Please read carefully – and sign where indicated. Ensure all you have read and understood all information and you accept the terms detailed in this form.

Patch Test / Waiver - Please tick A or B

Covid-19 Rules

Consent

Photographic Consent

To Comply with the Tattooing Act Please Answer Yes or No

Notes to Discuss