Microblading Consent Form

Microblading Consent Form
Client Details
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number

MobileHome
Email
example@example.com

Contact in case of emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number

MobileHome

Rows	AGREE
AFTERCARE: Aftercare instructions have been explained to me and a written copy (last page of this document) has been given to me to retain in my possession, which I will follow to the best of my ability. If I have any questions I will call or email you.
PAIN: I understand that a certain amount of discomfort is associated with this procedure. There can be pain even after the topical anaesthetic has been used as Anaesthetics work better on some people then others. Anaesthetic is not applied for the first pass as this will result in the microbladed hair strokes not being crisp, it is applied to the skin before the second pass.
ANAESTHETICS: I understand that topical anesthetics are used to numb the area to be microbladed after the first pass. Lidocaine, Prilocaine, Benzocaine, Tetracaine, and/or Epineohtine cream and/or liquid are used. If you are allergic to any of these please inform me now in the box below.
EXCESSIVE SWELLING or BRUISING: I understand that some swelling and bruising may occur. However this is extremly rare. Some people bruise or swell more than others. Ice packs may help reduce any swelling.
TANNING & SUN EXPOSURE: I understand that tanning beds, sun exposure, pools, some skincare products, and medications can effect my results.
SKINCARE: I understand that Retin A, Renova, Alpha Hydroxy Acids (AHA's), Beta Hydroxy Acids (BHA's), Lactic Acid and Glycolic Acids must not be used on treated areas. They will alter the colour and cause premature exfoliation of the pigment.
MRI or MEDICAL PROCEDURES: I will tell all skin care professionals and medical personnel about my microblading procedure, especially if scheduled for an MRI. Some pigments for semi-permanent makeup contain Iron Oxides which could mean the use of a low level magnet if you needed to be scanned for a MRI.
ASYMMETRY: Every effort will be made to avoid asymmetry, but our faces are not symmetrical, so adjustments may be needed during the follow-up session to correct any unevenness.
UNEVEN PIGMENTATION: I understand that implanted pigment colour can slightly change or fade over time due to circumstances beyond your control, and I will need to maintain the colour with future applications and a touch up session within 4-8 weeks. This can result from poor healing, infection, bleeding or many other causes. Your follow-up session will likely correct any uneven appearance.
SCAR TISSUE: I understand that successful colour saturation can NOT be guaranteed due to hidden scar tissue.
BROW COLOUR & SHAPE: I accept the responsibility to explain to you my desire for specific colours, shape and position for my eyebrow microblading procedure.
INFECTION & COMPLICATIONS: I acknowledge that the microblading procedure involves risks and there may be a possibility of complications during and/or following the procedure such as: infection, misplaced pigment, poor colour retention & hyper-pigmentation. Infection is very unusual. The areas treated must be kept clean, and only freshly cleaned hands should touch the area. See 'After Care' sheet for instructions on care.
TOUCH-UP: I have been advised that a touch-up session is highly recommended to make any adjustments to the shape and colour, and to fill any pigment that may have had poor retention. Touch-ups must be completed within 4-8 weeks of initial procedure.
ALLERGIC REACTION: There is a possibility of an allergic reaction. You must take a patch test to determine this.

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 the microblading procedure. I have been informed and it was explained to me the general nature of cosmetic tattooing as well as the specific procedure to be performed.

I have been informed of the possible risks and consequences of microblading and I understand that there might be complications and consequences associated with this procedure, such as: infection, scarring, or inconsistent colour.

I realise that patchy brows can be normal after my initial microblading brow procedure, which is why I am recommended to have a touch-up appointment 4-8 weeks after my first appointment. I understand that if I choose to not have the touch-up appointment within the 4-8 week time frame my brows may not last as long or look as good.

I understand that this cosmetic procedure is not fully permanent and may result in fading over time. I have likewise received and will strictly adhere to aftercare instructions given to me. Any adverse effects due to my failure to adhere to the instructions shall solely be my responsibility.

I have been advised to do a patch test to identify any allergic reaction to the pigment. Should I waive my right to a patch test, I release the therapist from liability if I develop an allergic reaction to any of the procedure.

I acknowledge that some changes might not be corrected in the event I undergo other laser hair removal, plastic surgery or other procedures.

I understand that photographs taken for comparison of the before and after procedure are part of the procedure.

I accept full responsibility for the decision to have this microblading procedure done. The cost for touch-up’s after this first procedure are not included.
Signature
I have received a patch test for the pigment/or I waive my right to having the patch test against advice. I release the therapist from liability should I have an allergic reaction.
Sign below.
Signature

How long will microblading last?

Once applied, microblading pigment does fade. How long your microblading results last will depend on your skin type, lifestyle and how often you get touch-ups.

The effects of microblading can last anywhere from 1-3 years. Once pigment from the procedure begins to noticeably fade, you will need to come back for a touch-up application. Touch-ups can be necessary 12-18 months, depending on your skin type and prefered look.

Microblading touch-ups are similar to getting root touch-ups for your hair. If you come when your microblading first starts fading, you can simply have the colour filled in. But if you wait longer than recommended, you may have to have the whole microblading procedure done over again on both of your eyebrows.

How long does microblading last on oily skin? If you have oily skin, you're still a candidate for microblading but the results might not last as long as they would on other skin types. High amounts of sebum (aka oil) being secreted from your skin can make it more difficult for the pigment to adhere and stay in your skin.

Other factors that can effect how long your microblading will last are:

Lifestyle, i.e if you live in a sunny climate or work outside in the UV rays all day then your brows will fade quicker.

Skin type, texture and age.

Medication such as HRT, thyroxin, cholesterol medication and antibiotics can cause pigment to fade quicker.

Preparation of treatment is followed correctly to prevent patchy, asymmetrical brows.

Aftercare advice is followed correctly otherwise the longevity of your brows may be compromise.

How oftern you get a touch up.
Preparation for treatment

You will get much better results when you properly prep. It all starts with a good canvas! The eyebrow area must be healthy, strong, non-sensitive and non-irritated. Here's how to get your skin ready for the procedure.

Do not wax/tweeze/ electrolysis or tint your eyebrows one week before the procedure.

Do not tan two weeks prior or have a sunburned face.

Do not have any type of facial/peel 2 weeks prior to treatment.

Discontinue Vitamin A/perscribed Retinol products one month prior to treatment.

Do not work out the day of the procedure.

Do not have botox 4 weeks prior- not waiting the appropriate time could cause asymmetrical results.

Do not take Fish Oil or Vitamin E one week prior (natural blood thinners).

In order to avoid excessive bleeding and poor colour deposit:
• Do not drink alcohol 24 - 48 hours before your tattoo.
• Do not consume coffee the day of your procedure.
• Do not take an aspirin or ibuproten for pain reliet the day of your procedure (this thins the blood).

Please wear your normal brow make up on the day of your treatment so I can see how you like to wear your brows.

Aftercare Advice- Absorb.Wash.Moisturise.

Please follow these instructions after the treatment to improve and prolong the results. If you do not follow these instructions it could greatly affect your microblading results.

I will apply a thin layer of cream over your eyebrows after the treatment. This helps the healing process and protects the eyebrows. I will give you a small pot of this same cream to take home with you.

The day of the treatment: Absorb
30 minutes after your appointment wipe over your brows with damp cotton wool to absorb any lymph and apply a small amount of the the aftercare cream using a clean cotton bud. Repeat this process every 3-4 hours for the rest of the day.
Apply your PhiBrow patches before going to bed.

Days 2-7: Wash
Wash daily to remove bacteria and dead skin. (Don't worry....THIS DOES NOT REMOVE THE PIGMENT!)
Gently wash your eyebrows each morning and night with water and an antibacterial soap like Dial Soap, Cetaphil or Neutrogena. With a very light touch, use your fingertips to gently cleanse the eyebrows. Rub the area in a smooth motion for 10 seconds and rinse with water ensuring that all soap is rinsed away. To dry, gently pat with a clean tissue. DO NOT use any cleansing products containing acids (glycolic, lactic, or AHA), or any exfoliants.

Days 2-7: Moisturise
Apply a rice grain amount of the attercare cream (morning and night) with a cotton bud and spread it across the treated area once cleaned and fully dry. Be sure not to over-apply as this will suffocate your skin and delay healing. The cream should be barely noticeable on the skin. Never put the cream on a wet or damp tattoo.

Important Reminders

Use a fresh pillowcase.

Let any scabbing/dry or flakey skin naturally exfoliate away. Picking can cause scarring or loss of colour.

No facials, botox, chemical treatments, laser treatments or microdermabrasion for 4 weeks.

Avoid hot, sweaty exercise for one week.

Avoid direct sun exposure or tanning for 4 weeks after procedure. Wear a hat when outdoors.

Avoid heavy sweating and long hot showers for the first 10 days.

Avoid sleeping on your face for the first 10 days.

Avoid swimming and hot tubs for the first 10 days.

Avoid makeup and sunscreen on the area for first 10 days. After 10 days however, do apply an SPF to your brows to avoid fading.

DO NOT rub, pick or scratch the treated area.

Avoid products that contain acids, such as AHAs and BHA's, around the eyebrow area.

IMPORTANT NOTE ABOUT SHOWERING:
Limit your showers to 5 minutes so you do not create too much steam. Keep your face out of the water while you wash your body, then, at the end of your shower, wash your hair. Your face should only be getting wet at the very end of the shower. Avoid excessive rinsing and hot water on the treated area.
Should be Empty:

Rows	Yes	No
Currently pregnant
Currently breastfeeding
Undergone botox treatment
Diabetes
Hepatitis A B C D
Had forehead/brow lift
Had facelift surgery
History of alcoholism
Any heart conditions
Had your brows tinted
Any autoimmune disorders
Oily Skin
Cancer
Undergone Chemotherapy or Radiation
Taking or have taken acne treatments in the past 3 months
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?
Have you ever had a chemical peel?
Have you ever had microblading before?
Do you have any moles, raised areas or scaring on or around your eyebrows?
Do you have or have you ever had eyebrow piercings?
Do you suffer with Eczema, Dermatitis, Psoriasis or Rosacea in the eyebrow area?
Do you have extremely thin skin?
Do you suffer with Haemophilia?
Do you have a bleeding disorder?
Are you taking medication for a thyroid condition?
Do you have problems with healing?
Do you suffer from Keloid Scarring?