Microblading Medical Consent Form

MEDICAL & HISTORY FORM

Micropigmentation & Microblading Procedures
Name

First NameLast Name
Address

Street Address

Town/CityCounty

Postcode
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Doctors Name
Doctors telephone number / surgery

Are you / have you?

Rows	Yes	No
Taken an aspirin or blood thinning medication in last 7 days?
Taken any mood altering drugs/substances in last 24 hours?
Pregnant or breast feeding?
History of cold sores/herpes/fever or blisters
Sensitive to latex
Required to take antibiotics during dental treatment
Resilient to numbing agents during dental treatment
Problems healing from minor wounds
Had problems with previous tattoos
Undergoing chemotherapy or radiotherapy
Currently using RETIN A or 'Alpha Hydroxy' skin care products, or having/recently had a facial chemical peel
Wearing contact lenses
Allergic to any metal / experienced problems with surgical needles
Had permanent make up procedures before
Taking immunosuppressive medication such as anti-inflammatory or steroids
Taking any medication
Allergic to any of the following topical antibiotic preparations (polysporin, epinephrine, bacitracin, neosporin, lidocaine, benzocaine, tetracaine or any other 'CAINE' family of drugs)

If you have answered 'yes' to any of the above, please give details below:

Are you / do you have?

Rows	Yes	No
History of skin diseases or major skin sensitivities
Eczema in treatment area
Vitiligo
Dermatitis
Regular dizzy/fainting spells
Asthema
Diabetic
Blocked tear ducts
Have current sunburn
Have current suntan
Psoriasis
Haemophilia
Rosacea
High/low blood pressure
Treatment for depression
Pacemaker fitted
Medical implants
Contemplating plastic surgery
History of plastic surgery

If you have answered 'yes' to any of the above, please give details below:

Do you / have you suffered from

Rows	yes	No
Heart conditions
Acne or Acutane treatments
Keliod or Hypertrophic scars
Stroke
Shortness of breath
Epilepsy/Seizures
Glaucoma
Cancer (any type)
Autoimmune disorders/diseases, other immune deficiency
Kidney disease
Hyper-pigmentation of skin (darkening)
Under/Over active thyroid
Allergies
Dry eyes
Diabetes
Chest Pains
Alopecia
Refractive eye surgery
Tricholtillomania
Ocular Herpes
Hepatitis/Jaundice/HIV
Excessive bleeding from minor injuries
Hypo-pigmentation of skin (lightening)

If you have answered 'yes' to any of the above, please give details below:
Details of any other medical condition not mentioned above:
List of all current medications and dosage
PLEASE NOTE: THE PRACTITIONER MAKES NO ATTEMPT TO, OR CLAIM TO PRACTICE MEDICINE. SOME INDIVIDUALS WILL HAVE COMPLICATIONS RELATED TO SEMI-PERMANENT MAKE UP APPLICATION. THESE COMPLICATIONS ARE USUALLY MILD, AND LAST ONLY A FEW DAYS. HOWEVER, EXTREME COMPLICATIONS ARE ALWAYS A POSSIBILITY, AS WITH ANY MEDICAL PROCEDURE, IN ALL CASES YOU ARE ADVISED TO SEEK THE GUIDANCE OF A MEDICAL PROFESSIONAL.

IF YOU ARE HEALTHY AND THERE ARE NO VISIBLE REASONS RESTRICTING YOU FROM RECEIVING TREATMENT, YOU MUST APPROVE THE AREA, TONE AND COLOUR BEFORE APPLICATIONS.

PLEASE SIGN BELOW TO STATE THAT THE ABOVE INFORMATION SUPPLIED IS CORRECT TO YOUR KNOWLEDGE, AND THAT YOU ARE NOT AWARE OF ANY REASONS WHY TREATMENT SHOULD BE WITHHELD, AND YOU ARE IN AGREEMENT OF THE ABOVE STATEMENT.
Client Signature
Date

MonthDayYear
Date
Therapist Signature
Date

MonthDayYear
Date
Clients Name
I duly authorise CARLY DEACON to perform the following Micro Pigmentation treatment and any other measures which in their opinion be necessary.

Area being treated   Signature

I understand that Micro Pigmentation is a minimally invasive procedure of infusing pigments into the skin to define, reshape and re-colour the eyebrows by way of anaesthetic tattooing. No guarantees as to the end results are given; I also understand that clinical results may vary for each individual. Signature

I have been given specific information upon the consultation and been given the opportunity to ask questions regarding the treatment.    Signature

I have completed the medical questionnaire and have disclosed my full medical history, I consent to disclose any changes in my current medical situation if they do arise during the course of treatments that I am receiving.    Signature

I understand that there may be some side effects associated with the treatment I am receiving such as bruising, slight swelling, scabbing, redness, skin discolouration and tenderness of the area that is being treated and that these effects are determined by the individual’s response to treatment.    Signature

I am also aware that pigment migration may occur, which is entirely dependent on the skins natural ability to draw the pigment into the correct layer.    Signature

I am fully aware that the treatment may require a ‘Top Up’ treatment/session to acquire the final results and have discussed this and am happy with the fee for this.   Signature

I certify that I have been fully informed of the nature and purpose of the treatment, expected outcomes and possible complications and risks, I understand that no guarantee can be given as to the final outcome obtained.    Signature

I certify that the decision to have the treatment has been solely based on my desire to do so and that I will follow the aftercare instructions given to me in order to assist the final result obtained and if I do not it may cause complications.    Signature

I also herewith relieve CARLY DEACON from any liability from an adverse reaction to any of the treatments given as I have had a patch test prior to having the treatment.   Signature

I have asked all questions and I am happy with the answers, I have been given the appropriate aftercare advice which I know I must adhere to and I realise this is a semi-permanent procedure and top ups will be required to boost the colour (sooner than normal if exposed to the sun).    Signature
Client Signature
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date
CLIENT RECORD FORM

________________________________
Name

First NameLast Name
Chosen treatment, details of desired outcome and colours agreed
Patch test date and results
Details of treatment
Follow up treatments
CLIENT CONSENT TO PROCEED FORM

________________________________
Clients name

First NameLast Name
I confirm I have disclosed to my practitioner ALL medical conditions, medications and any contra-indications that may effect the results of the procedure, or be detrimental to my health.
Signature
Date

MonthDayYear
Date
I confirm that I have had a patch test with no adverse effects.
Signature
Date of patch test

MonthDayYear
Date
Date

MonthDayYear
Date
I confirm I am happy with my eyebrow template and happy for the procedure to go ahead.
Signature
Date

MonthDayYear
Date
I confirm I am completely satisfied with the outcome of my eyebrow procedure and understand that there is an element of swelling which will slightly effect the shape, as previously explained.
Signature
Date of patch test

MonthDayYear
Date
PHOTO RELEASE CONSENT

________________________________
I First Name Last Name hereby give my consent for CARLY DEACON to use any photos of any procedure/treatment that she administers on me, before and after, for advertising and promotional purposes.
Signature
Name printed
Date

MonthDayYear
Date
Should be Empty:

MEDICAL & HISTORY FORM

CLIENT RECORD FORM

CLIENT CONSENT TO PROCEED FORM

PHOTO RELEASE CONSENT