Microblading Consent Form

PERMANENT MAKEUP CONSENT FORM

Please Fill Out Prior To Appointment
Client Details
Date

Month Day Year
Date
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Birth Date

Month Day Year
Date
Age
At Time of Appointment

Contact in case of Emergency
Name

First Name Last Name
Phone Number

Area Code Phone Number

Contraindications For Procedure:

1. Pregnant/Nursing

2. Chemotherapy/Radiation Treatments (Currently Receiving)

3. Sick with Cold/Flu/Fever/Coronavirus

4. Active Herpes On The Face

5. Eyelash Extensions & Contact Lenses Must Be Removed For Eyeliner

Require Waiting Periods:

1. Lasik/Cataract Surgery (Eyeliner Only-1 Month Prior & 3 Months Post-Op)

2. Latisse (Eyeliner Only-2 Weeks)

3. Botox (2 Weeks)

4. Fillers (2 Weeks)

5. Accutane (1 Year)

6. Suntanned Skin (1 Month)

7. Retinols/Glycolic Acid/Vitamin C Peels (1 Month)

8. Shingles Shot (1 Month)

9. Laser Treatment (8 Weeks)

10. Coronavirus Vaccine (2 Weeks)
INFORMED CONSENT I certify that I am over the age of 18, and not under the influence of drugs or alcohol, and I consent to receiving Permanent Makeup with Deanna, at The Shaped Look. I do not have any health conditions or issues that will prevent me from having the procedure. I acknowledge & have read the Pre-, During, & Post-, Procedure on The Shaped Look website and I agree to strictly adhere to such instructions. I understand that the process used to apply color is not a one-step process & requires subsequent visits to achieve desired results. I understand that with time pigment can & will fade & change color according to metabolism, skin type, medications, age, smoking, alcohol, skin exposure, Retin-A & Glycolic Acids. I acknowledge that no guarantees will be made concerning the results of this procedure. I understand that this is a tattooing process, therefore not an exact science, but an art. I understand the nature of the procedure & that adverse affects may occur such as redness, swelling, & tenderness. I accept responsibility for determining shape, color, & position of the pigment that will be applied. I understand that from 48 hours prior, during, & after the procedure there are no refunds. I give consent to photograph the treated area & this photograph may be used by The Shaped Look, on my portfolio, social media, & website for advertising purposes. I understand that a 2nd appointment (Perfection Visit), will need to be performed 6-8 weeks from initial visit. If not performed in this time frame there will be additional fees. I can have a patch test to identify any allergic reaction to any medicine or anesthetics at a Consultation appointment. Should I waive for the test, I release the Deanna, from The Shaped Look, from liability if I develop an allergic reaction to any of the procedure.

I certify that the information in the above questionaire is accurate.

Signature

Clear

For Tech Only/Notes
Should be Empty:

	Yes	No
Currently Pregnant
Currently Breastfeeding
Had history of Methicillin-resistant Staphylococcus aureus (MRSA)
Had undergone Botox treatment
Has or any family history of Diabetes
Has Hepatitis A B C D
Had Forehead/Brow Lift
Had Facelift Surgery
History of Alcoholism
Has a Heart Condition
Had a Brow Lash Tinting
Has Autoimmune disorder
Has Oily Skin
Has, had, or any family history of having Cancer
Had undergone Chemotherapy/ Radiation
Taking or have taken acne treatments in the past 3 months
Had a Tan treatment
Difficulty numbing with dental work
Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc
Allergic reaction to any medications
Allergies to metals, food, etc,
Any diseases other than listed here
Do you use facial care treatments?

PERMANENT MAKEUP CONSENT FORM