CLIENT CONSULTATION & MEDICAL HEALTH HISTORY FOR MICROBLADING/PMU

Name

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Date of birth

Date

Phone

Format: (000) 000-0000.

Email

example@example.com

Emergency Contact Name

Do you have any concerns about your appointment?

What results are you going for? Ex. more shape, symmetry, natural looking brows, etc.

List any medications you have been taking in the last 6 months including vitamins, supplements, aspirins, etc.

Have you ever had an allergic reaction to one of the following?

Have you ever had one of the following?

I,*am over the age of 18, am not under the influence of drugs or alcohol and desire to have microblading of the eyebrows performed. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me.
Signature*

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, allergic reaction, scarring, inconsistent color, and spreading, fanning, or fading of pigments. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. I request the microblading procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure. I understand that while this is sometimes referred to as semi-permanent in nature, due to each individual's reaction to pigment, the length of time pigment is present cannot be guaranteed. In some cases, pigment will be permanent.
Signature*

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my permanent cosmetics. I acknowledge some of these potential adverse changes may not be correctable.
Signature*

I have received pre- and post procedure instructions and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure. If I am on any medication for depression or any other mood altering prescription, I will advise my technician.
Signature*

I understand that the taking of before and after photographs of the said procedure are a condition of such procedure. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and the procedure process. I accept full responsibility for the decision to have this cosmetic tattoo work done.
Signature*

NO. OF VISITS REQUIRED2 COST OF PROCEDURE(S)$399.00 + tax

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. IF YOU ARE UNSURE ABOUT A PARTICULAR DETAIL, PLEASE ASK.

Microblading/PMU is a way of cosmetic tattooing. Re-touch procedures may be required. A healing period of 6 weeks is required before a touch up procedure can be performed. On the rare occasion, the pigment may migrate under the skin. Procedure of microblading/PMU may be slightly uncomfortable. The pigments will fade. Immediately after the procedure, the pigment can appear 30-50% darker than the desired result. Results will heal 30-50% lighter than initial results. Although numbing cream is used during the procedure, slight discomfort/sensitivity can still be felt throughout procedure. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be applied to pregnant women or nursing mothers. Permanent cosmetics cannot be applied to any person under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after microblading procedure, you should notify your doctor. You can be assured that the procedure results will look acceptable for you to appear in public without additional makeup on the affected area.

I have recieved after care instructions and am fully aware of the after care procedures.

I have full understood the information provided above. I can confirm all the information provided by me is correct and truthful

Client Signature

Client Printed

Date

Technician Signature

Technician Printed

Date