New Client Profile

New Client Profile

Your privacy is very important. The following information is only used to assess your PMU goals, determine what treatments are appropriate for you and to avoid any possible reactions.
Full Name*

First Last
Birthdate:*
ex. 01/05/1960
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
ex. 555-555-5555
E-mail*
We will never SPAM or sell email addresses to third parties.
Occupation*
Emergency Contact*
name and phone
What is the best way to contact you?*

Phone callEmailTextAll
How did you hear about us?*

Skin Type
Select one
Select one*
What would you like to improve about your brows, lips, hairline, eyes, etc?:
shape, color, density, thickness, etc.
Do you have any permanent cosmetics or tattoos on the areas being treated?*

NOYES
Do you follow a regular exercise program?*

NOYES
If yes, please explain:
After your treatment you will need to avoid working out, heavy sweating, steam rooms and/or saunas for at least 7 days.
Smoking greatly reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your treatment.

Informed Consent & Release from Liability
You must carefully review the information provided in order to make an informed decision as to whether to undergo the Permanent Makeup Procedure Selected. Semi-Permanent & Permanent Makeup is a form of cosmetic tattooing for the eyebrows, eyes, scalp, face, areola, and lips. Microblading is a manual (handheld pen) technique that creates the appearance of hair strokes in the skin. The results are a realistic illusion of naturally fuller, thicker eyebrows. Microblading is a two-step process, clients require a touchup 6-8 weeks after the first appointment for retention. This will be scheduled after your initial appointment. Because a much smaller amount of ink is implanted into the skin, compared to fully tattooed eyebrows, microblading should last 12-18 months (individual results will vary). Therefore annual maintenance is recommended (this is still considered permanent makeup due to the permanence of the markings). PMU will last 3-5 years. (Nano brows, Liner, Smp, Areolas, Tiny Tattoos, etc.) Initially, the color will appear more vibrant or darker compared to the end result. Usually within 7 days the color will fade 40‐50% and the treated area will flake or scab. DO NOT PICK. Scabs will fall away naturally, picking will remove implanted pigment. Your brows will appear uneven, any loss of pigment or correction will be addressed at your touchup appointment. Around 10-14 days your area of service will be completely healed and look more natural. A perfect result is not a realistic expectation. Cosmetic tattoos cannot be performed if you are pregnant or nursing or under the age of 18. No person maybe tattooed who appears to be under the influence of alcohol or drugs.
The risk and dangers include, but are not limited to the following:~I understand this is a 2-step process and it is usual to expect a touch‐up no later than 6-8 weeks after the initial session. After 6-8 weeks will require additional cost.~You may experience minor bleeding during your treatment. There may be swelling and redness following the procedure, which will subside after 1-5 days.~Allergic reactions to pigment, anesthetics or other materials used can occur. Possible scarring may occur.~Risk of infections can occur. Please follow aftercare instructions correctly. Contact us ASAP if you suspect signs of infection.~There is a possibility of pain or discomfort, even though a topical anesthetic is used.~I understand that Retin A, Renova, Alpha Hydroxy and Glycolic Acids must not be used on the treated areas. They will alter the color.~I understand that sun, tanning beds, pools, some skin care products and medications can affect my permanent makeup.~I accept the responsibility for explaining to my technician my desire for specific colors, shape, and position for any procedure that will be done.~All instruments that enter the skin or come in contact with bodily fluids are single use and disposed of after each session. Cross contamination guidelines are carefully adhered to.~I am not pregnant or nursing.~I will not be under the influence of any drugs or alcohol during my treatment.~I understand results are not guaranteed and all services are non-refundable.~I have been duly informed of the risks, possible complications and consequences as listed above.~I have received a written copy of after care information and I have read and fully understand such written care instructions, which I will follow to the best of my ability. If I have questions I will call or email. I fully understand the information provided above, have had my questions answered and agree to all terms and conditions of this document.I hereby release Shannon Crowley, MicrobladingFiend LLC. and affiliates from any liability arising from risks that are known and/or unknown during the microblading procedure. And therefore, I agree to allow MicrobladingFiend LLC. (Shannon Crowley) to perform services on me.

Preparing for your appointment
DAY OF PROCEDURE and at least 12 hours prior to:

NO sweating (no working out); NO caffeine (coffee, energy drinks, etc.). NO alcohol. DO NOT have sunburned skin on face/area of desired work.

ONE WEEK BEFORE PROCEDURE(5-7 days):

discontinue all blood thinners such as: aspirin, vitamin E, ibuprofen, naproxen, niacin, fish oil, herbal supplements (physician clearance is required if blood thinners are medical necessary).
NO waxing or threading.

LIPS:

Take antiviral medication if you are prone to cold sores/ fever blisters/ HSV to prevent post treatment outbreak. The pores will be open and highly susceptible to outbreaks after if you have had them before! It is your responsibility to ensure you take it atleast 5-7 days before!!

TWO WEEKS BEFORE PROCEDURE (14 days):

NO eyebrow tinting, NO tanning bed, sunbathing. NO enzymatic, lactic or chemical peels. NO glycolic or salicylic acids in skin care. NO exfoliationg treatments. NO Botox, Dermal Fillers. NO AHA products, Retinols, and laser skin resurfacing treatments. Discontinue brow and lash growth serum.

ONE YEAR BEFORE PROCEDURE: discontinue Accutane & any acne treatments like Accutane!

Allow up to 3 hours for your appointment. It's recommended your 2nd session is within 6-8 weeks.
PLEASE NOTE: - you will be more sensitive during your menstrual cycle.

Take advantage of my customer referral program, you will receive special bonuses & deals for client referrals.

For more information on news and offers, please visit www.Microbladingfiend.com
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform my technician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Shannon Crowley, MicrobladingFiend LLC, it's artists and affiliates from liability and assume full responsibility thereof.*

I understand the cancellation policy.
TRAVEL: I understand, the touchup appointment is my responsibility. It is not the responsibility of the artist to travel for the touchup unless otherwise agreed to in writing. I understand, a travel fee may apply and was communicated at the time of booking. In the case of travel a 14 day cancellation period applies and all deposits are non-refundable*

I understand the cancellation policy.
To cancel an appointment, please do so at least 48 hours prior to your appointment. Cancellations within 48 hours will result in the loss of the nonrefundable deposit. A cancellation of 24hrs or less will result in the loss of the deposit and be charged a fee of $100. A No-Show is a result in the loss of your deposit and a $150 charge.*

I understand the cancellation policy.
I grant permission to Shannon Crowley, MicrobladingFiend LLC, it's artists and affiliates to use my photos and all forms of media for marketing, promotional literature, educational and social media purposes.

I grant permission.
Date*

MonthDayYear
Signature*
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Deposit:

Nonrefundable Deposit$55.00

For any and all appointments the $50 nonrefundable deposit is required to hold your spot. For multiple appointments please select additional deposits for each service.

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