Name
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First Name
Last Name
E-mail
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Phone Number - Text Only
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What is your daily skincare routine, and products that you use?
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Date of Birth/Age
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Have you previously had any microblading or permanent makeup done to your brow or lip area?
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Yes - Brows
Yes - Eyeliner
Yes - Lips
Yes - Brows & Lips
No - No pmu/microblading has ever been done on me
If you do have previous work done by another artist, how long was it since your last session? Please note that Adrienne will only work on top of previous artists' work if at least 80% faded, and she feels comfortable doing so. All new clients of Adrienne's are considered New Initial sessions, not touchups/colorboost sessions
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Never had work done by another artis
Less that 1 year ago
1-2 years ago
3+ years ago
Have you looked over the Microblading FAQ section of my website?
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Yes
No
What is your skin type?
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Normal/Dry (small pores to none visible)
Combination (Some areas dry, some areas oily
Oily (large pores, gets shiny by end of day)
Type option 4
Do you understand that permanent cosmetics DO NOT REPLACE makeup. Permanent Cosmetics heal IN the skin, while makeup sits ON TOP of the skin.
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Yes, I understand
Why are you looking to have permanent makeup done?
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Please read these statements carefully - Permanent cosmetics are a form of tattooing. - Re touch procedures may be required. - A healing period of 4 to 6 weeks is required before any touch-up procedure can be performed. - On rare occasions the pigment may migrate under the skin. - Application of permanent cosmetics can be uncomfortable. - The pigments will fade. - Immediately after the procedure, the pigment can be 30 to 50% darker than the desired result. - There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare. - A negative allergy test result will not guarantee that you will not have an allergic reaction. - Infections can occur if aftercare is not followed. - Allergic reactions to anaesthetics can occur. - There may be swelling and redness following the procedure. - You may experience minor bleeding. - If you have a MRI scan within 3 months your permanent cosmetics procedure we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.
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I have read and understand the above statement
Eyebrow Photos
Please take a close up photo of each of the views requested below and upload them in the appropriate file upload
Please upload current full face photos of your bare brows (no makeup) in good natural lighting such as outside or by a bright window
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Upload a File
Cancel
of
Please select the option the best describes the microblading treatment required
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Fully Reconstruct
Define Existing Brows
Make Existing Brow Bigger
Other
Please upload pictures of brows/lips that you like and would want to use as inspiration to this service. Shape, color, and thickness.
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Browse Files
Cancel
of
what do you like about the selected inspiration photos you submitted?
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What do you currently like about your current brows/lips?
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What do you currently dislike about your brows/lips?
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any additional questions?
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How did you hear about me/who referred you?
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Have you taken any of the following in the last 48 hours? Refrain from all of these 48 hours before your appointment time
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Rows
Yes
No
Aspirin
Ibuprofen
Coumandin
Alcohol
Have you ever had an allergic reaction to any of the following:
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Rows
Yes
No
Anaesthetics
Adrenaline
Latex Rubber
Vaseline
Crayons
Metals
Drugs
Paints
Lanolin
Foods
Medication
Glycerine
Lidocaine
Another allergy not listed
If 'yes' or 'another allergy' please provide additional information below
Have you received chemotherapy or radiation treatment in the last year?
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Yes
No
Please select yes to the following that apply to you;
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Rows
Yes
No
Abnormal Heart Condition
Cold Sores (herpes simplex)
Mitral Valve Prolapse
Heart Murmur
Rheumatic Fever
Pacemaker
Artificial Heart Valves
Anaemia
Haemophilia
Prolonged Bleeding
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Diabetes
Epilepsy
Fainting Spells or Dizziness
Thyroid Disturbances
Liver Disease
Kidney Disease
Glaucoma
Stomach Ulcers
Tumours, Growths or Cysts
Cancer
Tuberculosis
Stroke
HIV
Prosthetic Hip or Joint
Palpitations
Hepatitis
Cataracts
Blurred Vision
Dry Eyes
Eye Infection present
Alopecia
Recent Hair Loss
Watery Eyes
Contact Lenses
Eyelid Surgery
Chapped Lips
Trichollomania
Gore-Tex Implants/Silicone Injections
Fat Transfer Injections
Botox Injections
Collagen Injections
Hypertrophic Scars
Keloid Scars
Scar Easily
Healing Problems
Bruise or Bleed Easily
Sensitivity to Cosmetics
Use of Sun bed
Acutance within 6 months
Cortisone within 6 months
Chemical or laser peel within 6 months
Retin A within 6 months
AHA preparations within last 2 weeks
General Consent & Procedure Permit
1. I hereby authorise Adrienne Fye (microblading technician) 2. Of Breathe Peace Wellness Spa to perform the microblading/ombre brow treatment upon myself. If any unforeseen condition arises in the course of this procedure(s), calling in their judgement in addition to, or different from those now contemplated, I further request and authorise the technician to do whatever they deems advisable and necessary in the circumstances. 3. I accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. 4. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I confirm I have completed a patch test for this procedure, within 6 months of the treatment date. 5. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-3 years. 6. I 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. 7. 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. I understand this is why I need to return for a retouch procedure. 8. I understand that a retouch procedure will be performed 1-3 months after the initial procedure and after a 3-month period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties. 9. 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 and smoking - Post procedure care treatment 10. Upon completion of the procedure there may be swelling and redness of the skin, which will subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately following the procedure, however, using cosmetics, excessive perspiration wetting and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. You can however, be assured the procedure, even after only one treatment, looks acceptable and you should feel comfortable appearing in public without additional makeup on the affected area. 11. I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary in colour according to skin tones, skin type, age and skin conditions. I understand that some skins except pigment more readily than others and no guarantee to an exact effect or colour can be given. 12. I am aware that the lip procedures may stimulate any dormant virus such as herpes (cold sores). I am informed that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment. 13. To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol, pregnant or breastfeeding. 14. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. 15. Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by Adrienne Fye (microblading technician) 16. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the microblading procedure(s)
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I have read and understand the above information
Topical Anaesthetic Form
Allergic Reaction– Allergic reaction can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptom associated with allergy. Numbness - We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is totally numb while others say they experience some discomfort. Procedure – For all procedures a cream or gel topical anaesthetic is used. These products are perfectly safe, and can be purchased over the counter from any chemist. The anaesthetic is placed over the treatment area for between twenty to thirty minutes then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between one and four days. You should always follow your post procedure instructions.
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I have read and understand the above information
Authorised Use Only
Skin Type
Pigment Colour
Consultation Date:
Treatment Date:
Top-Up Date:
Location
Treatment Price
Top Up Price
Rows
Date Completed
Skin patch test
Pre instructions
After Care instructions
Before photos
After photos
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