New Client Microblading Consultation Record

Appointment Date*

Date

Appointment Type

Name*

First NameLast Name

Phone Number

Phone Number*

Email*

example@example.com

Age?*

Preferred Contact Method?*

I have chosen a cosmetic procedure that is not medically necessary.
The procedure cannot take place if you are pregnant or breastfeeding.
In the first 7 days eyebrows/lips will be up to 40% darker eyebrows will be and 10-15% thicker than the final result.
Any swelling or redness that you may experience is normal and will subside.
The shape created is according to your facial proportions, and symmetry is always the main aim. You will get a chance to review the shape during the pre draw before we begin.
Your technician cannot guarantee an exact colour due to how pigments heal differently in all individualsand in rare cases the pigment may migrate under the skin.
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. If you have oily skin please mention this as other techniques maybe more suitable for long lasting results.
You will be required to return for a top treatment between 4-8 weeks 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 will be 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 somewhere between 9-18 months.
Due to each skin type being different the permanence of the treatment cannot be guaranteed.
Pigments in lip blush can contain iron oxides. It is essential you inform your radiologists before a CT or MRI Scan.
We want to manage your expectations, so please understand and appreciate that the results you get at the end of your procedure may vary from individual to individual depending on a number of factors including, the colour pigment blended with your natural skin tone, the shape and position of your facial features, any medication that you are taking, your skin characteristics (dry, oily, sun-damaged, thin, thick), the PH balance of your skin, diet, alcohol intake and/or smoking and any post operative care treament (if applicable). If the end results are not what you expected, you have no automatic rights to make requests for any changes. Please refer to our Customer Service Policy (link below).

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.

Booking fees 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 booking fee) 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.

To read our Customer Service Policy - click here

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

Signature*

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?*

Date

Signature*

I understand that my technician 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 or Lip Blush. 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, to carry out the treatment as requested by me on this consent and treatment agreement.

Signature*

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

Are you over the age of 18?*

YesNo

Are you pregnant or Breast feeding? (If so, we can’t do treatment)*

YesNo

Are you currently under the care of a doctor or hospital specialist? (If yes, you will need GP referral)*

YesNo

Are you under the influence of drugs or alcohol?*

YesNo

Have you taken Aspirin or Ibuprofen in the last 2 days?*

YesNo

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

YesNo

If YES how long ago was this?

If YES what was the procedure?

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/Lip Blush today?
Do you have any allergies or have you experienced any reactions to any medicines, anaesthetics, Lanolin, paints, latex rubber, metals, food, crayons, nuts, hair dyes, Lidocaine, Glycerine or antibiotic ointments 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 use any creams or medications to thin the skin?
Have you had treatment for cancer in the last 12 months, including chemotherapy or radiation?
Do you have a MRI scan scheduled in the next 3 months?
Laser or IPL scheduled in the next 3 months?
Do you give blood?
Prior to dental procedures do you receive antibiotic therapy?
Do you suffer from any infectious diseases?
Do you have any respiratory problems?
Do you have eczema/psoriasis in the eyebrow or lip area?
Do you have any keloid scars?
Do you have cataracts?
Do you have blurred vision?
Do you suffer with dry eyes or watery eyes?
Do you suffer from eye infections?
Do you suffer from Alopecia?
Do you suffer from Occular Herpes?
Do you wear contact lenses?
Have you had eyelid surgery?
Do you suffer with chapped lips?
Do you have Trichollomania?
Have you had recent hair loss?
Do you suffer from Cold Sores (herpes simplex)?
Do you experience dizziness?
Do you have Gore-Tex Implants/Silicone Injections?
Do you have other tatoos?
Have you had Fat Transfer Enhancement?
Do you bruise or bleed easily?
Have you had Botox enhancement?
Do you have Dermal Fillers i.e restylane?
Have you had a Chemical or laser peel within 6 months?
Do you scar in a raised manner?
Do your scars heal a darker colour than the rest of your skin?
Have you had Retin A within 6 months?
Have you had AHA preparations within last 2 weeks?
Sensitivity to Cosmetics?
Acutance within 6 months?
Steroids within 6 months?
Do you tan regularly?
Do you use of Sun beds?

Please fill out the following table with a tick to indicate if any of the following relate to yourself. If you have any of these medical conditions you will need GP referral:*

	Yes	No
Heart Condition
Palpitations
Mitral Valve
Prolapsed Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
Shingles
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Auto immune system conditions
Thyroid Disturbances
Hepatitis
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Systemic Lupus
Erythematosus

If the answer was yes to medication please list and specify what for?

If you suffer from any infectious diseases please list below?

Please tell us what your dream brows/lips 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.

I give my consent for a cosmetic tattooing procedure to be carried out, which is undertaken at my request.

I have visually seen my Pre Drawing results and am satisfied with the width and shape. I understand that further amendments of the width and shape will need to carried out at my own cost.

Signature of Client*

Name*

First NameLast Name

Date:*

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

Consent

Photographic Consent

To Comply with the Tattooing Act Please Answer Yes or No

Notes to Discuss