Semi-Permanent Makeup Consultation Form

Ombre Powder Brow Consultation Form
Select Service*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Age*
Email*
example@example.com
Instagram @*
If none, put NA
Preferred Language*

EnglishSpanish
Do you wish to conduct an allergy patch test prior to procedure? NOTE: If yes, full service cannot be done same day.*

YesNo
Emergency Contact*
Include full name, phone number, and relation
Have you received Chemo Therapy in the past year?*

YesNo
Are you currently taking any medications?*

YesNo
Please list any mediation you have taken in the past 6 months and their purpose.*
Do you have any allergies?*

YesNo
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)*
Are you pregnant?*

YesNo
Are you breastfeeding?*

YesNo
Do you have any implants?*

YesNo
Do you have any Botox or other injectables?*

YesNo
Do you participate in outdoor recreational activities?*

YesNo
If so, do you understand that you need to protect your cosmetic tattoo from sweat, water, and direct sunlight?*

YesNo

Please check below if you have the following medical condition:*

	Yes	No	Remarks
Hair Loss
Trichotillomania
Alopecia
Prolonged Bleeding
Cancer
Low Blood Pressure
High Blood Pressure
Liver Disease
Sensitivity to Cosmetics
Circulatory Problems
Thyroid Disturbances
Anemia
Fainting Spells or Dizziness
Hyperpigmentation
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
HIV positive
Venereal Disease
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia
Hypertrophic or Keloid Scars
None of the above

Have you had any type of Permanent Make Up procedures on your brows before?*

YesNo
If so, please explain
If so, when did you have it?

MonthDayYear
Date
Have you had a Chemical or Laser Peel within 6 weeks?*

YesNo
Have you taken Accutane in the last year?*

YesNo
Have you used a Retinoid, Retin-A, Differin, Renova, Benzoyl Peroxide, Salicylic Acid, Tretinoin or similar in the last 14 days? If so, which one?*
If none, put NA
How did you hear about us?*

InstagramFacebookGoogleReferral
What are your main concerns relating to your eyebrows? What would you like to improve?*
Please be as detailed as possible
Please upload a photo of your eyebrows without make up using the back camera of your phone and flash/natural lighting. *

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Pre-Procedure Care

2 WEEKS PRIOR: Avoid waxing your eyebrows (waxing removes the very first layer of the Epidermis leaving your skin very irritated and sensitive), exfoliating your skin, products that contain glycolic acid, VITAMINS A & C, Retinol, and chemical peels. DAY PRIOR: Avoid alcohol and any medications that will thin the blood. Thinning of the blood may cause bleeding during the service thus affecting how the skin holds the pigment and creating inconsistent results. DAY OF: Do not drink any caffeinated drinks including coffee, teas, energy drinks, etc.
Post-Procedure Care

It not recommended to schedule an Ombre Powder Brow session prior to a special event or trip. Similar to a regular tattoo, expect your brows to scab up and peel. Keep your brows bare! Don’t use any creams, oils, or makeup during healing (except for healing creams like Afterinked if instructed.) AVOID SWEATING OR WETTING! This includes swimming. You can continue showering and/or washing your face while lathering around the brows. If you spend much time outdoors, use SPF (on the skin only) and a hat/cap to avoid direct sunlight on the brows. Once the brows have healed, apply SPF on the brows for a longer-lasting color. If you do sweat, you may gently wash the area with mild antibacterial soap + lukewarm water to avoid an infection. It is recommended to stop the use of all heavy chemical exfoliants (Retinol, Tretinoin, Alpha Hydroxy (AHA), Vit. A) as they will significantly lighten results. Please note that this is an average timeline of the healing process. It is not guaranteed that your skin will heal this exact way. MORE DETAILED INFORMATION WILL BE SENT TO YOU VIA TEXT.
Acknowledgement*

I understand that this procedure cannot guarantee 100% expected results.I allow the center to take photographs for case review which is before and after.I allow the center to use this photograph for a marketing campaign or advertising.I release the center for any liabilities related to the treatment and result specifically allergic reactions and applied pigmentation.I understand that I need to follow the instructions in terms of pre-procedure and post-procedure.I understand that permanent and semi-permanent cosmetics are a form of tattooing.I confirm that a healing period is required before the next or before the touch-up treatment.I understand that this procedure might be painful and requires patience.I understand that there might be an allergic reaction with or without conducting a patch test.I understand that I might experience infection, minor bleeding, swelling, and redness.I confirm that I have read, understand, and answered this consultation form accurately.I confirm that I answered all questions truthfully and correctly.
Please upload a photo of your valid government ID.*

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Signature*

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Date Signed*

MonthDayYear
Date
Artist Signature

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This is for the Artist only. Please do not sign.
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