Eyelash Extension

Micropigmentation and/or Microblading Consent Form
Appointment Date

MonthDayYear
Date of appointment
Hour MinutesAM/PM Option
Client Information
Name (As it appears on ID/DL)

First NameLast Name
OccupationBy which method did you hear form us?
Date of Birth

MonthDayYear
Date
Address

Street Address

Apt. Unit

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Emergency Contact Information

First NameLast Name
Emergency Contact Number
Format: (000) 000-0000.
Treatment to be performed:
Skin Type:
*If you have inflammation, swelling, cuts or abraisons, in the treatment area, the procedure cannot be done.*
*All fields are VERY important, please DO NOT IGNORE ANY.... Thank you !*
Have you had previous tattoo or micoblading performed on eyebrows before ?
If yes, when? And what service ?
Are you pregnant or breastfeeding ?
Keloid scarring ?
If yes, what areas ?
Facial or dermatological treatments?
If yes, which one ? And how long ago?
Are you taking blood thinners ?
Facial Botox ?
If yes, how long ago?
Laser hair removal ?
If yes, how long ago?
Are you under any medical treatment ?
If yes, which one?
Please indicate any medications you are taking: (including aspirin)
PLEASE CHECK ANY OF THE FOLLOWING THAT MAY APPLY TO YOU:
RELATING TO THE SKIN

Other
Other Medical Information
If none, please submit N/A
By checking the following boxes, confirm that you willingly consent to the following terms and conditions:

I am hereby notified of the possible risks and dangers associated with the application of each tattoo, micropigmentation and/or microblading procedure. These risks and dangers include, but are not limited to, at least the following: The possibility of discomfort or pain, the performance of the markings, the risk of infection, and the possibility of allergic reaction to the pigments or other materials used.In case of not obtaining the desired results after the third appointment, it would be due, either to the type of skin, physical activities, the consumption of medications, exposure to the sun, getting into pools, excessive bleeding during the treatment or diseases suffered by the patient, and therefore, it would not be possible to make a fourth appointment, since the skin would be very damaged and there would be pigment migration in the skin. In case of not obtaining the desired results after the third appointment is due to the previous mentioned, and not the performance of the artist in my treatment.
*Clients results will vary from person to person and using a pencil or powder may or will still be needed. We have no control over your body's healing process and each time a procedure is done the pigment will have less retention due to scar tissue.*
How your body heals the treated area is 100% out of the control of the technician. This is 100% your body's job even when following the aftercare fading, blurring and poor retention can still happen depending on your skin type and lifestyle. This is NOT the fault of the technician.
*I have completed this form to the best of my ability and acknowledge and agree to inform the technician on any changes in the above information. I have been informed and understand the contraditions to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsutable.*
Client Signature
Date

MonthDayYear
Date
Should be Empty:

Micropigmentation and/or Microblading Consent Form