Microblading and Shading Consent Form

Microblading and Shading Consent Form
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Please upload your ID *

Front and Back of ID required. Please bring same ID during appointment too.
Cancelof
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.

**Please read and initial each statement:**
1. **Purpose and Nature of Procedure:**
- I understand that microblading and shading involve implanting pigment into the skin to create semi-permanent eyebrow makeup.
- I am aware that the procedure can enhance the appearance of my eyebrows.
Initials: Enter Initials here

2. **Possible Risks and Complications:**
- I acknowledge that there are risks associated with the procedure, including infection, allergic reactions, and skin irritation.
- I understand that pigment may fade, change color, or spread over time, and touch-ups may be necessary.
Initials: Enter Initials here

3. **Pre-Procedure Requirements:**
- I have disclosed any medical conditions, medications, or allergies to the technician.
- I have followed all pre-procedure instructions provided by the technician.
Initials: Enter Initials here

4. **Post-Procedure Care:**
- I understand the importance of following post-procedure care instructions to ensure proper healing and pigment retention.
- I acknowledge that failure to follow these instructions may affect the results and longevity of the procedure.
Initials: Enter Initials here

5. **Results and Maintenance:**
- I understand that the results of microblading and shading vary from person to person and are not guaranteed.
- I am aware that touch-ups may be needed to maintain the desired look.
Initials: Enter Initials here

6. **Photography Consent:**
- I consent to the taking of photographs before, during, and after the procedure for documentation and marketing purposes.
Initials: Type a label

7. **Liability Waiver:**
- I release the technician and the establishment from any liability related to the procedure and any potential adverse reactions or outcomes.
Initials: Type a label

8. **Acknowledgment and Agreement:**
- I have read and fully understand the information provided in this consent form.
- I have had the opportunity to ask questions and have received satisfactory answers.
- I voluntarily consent to undergo the microblading and shading procedure.
Initials:   Type a label

Signature:   Signature   Date:   Date

Name:   First Name   Last Name

**Medical History Questionnaire:**

1. Do you have any allergies?       Yes   No
If yes, please list:

2. Are you currently taking any medications?   Yes   No
If yes, please list:

3. Do you have any medical conditions that may affect the procedure?
Yes   No     If yes, please explain:

4. Have you had any previous microblading or shading procedures?
Yes   No. If yes, when was the last procedure?

**Pre-Procedure Instructions:**
- Avoid caffeine, alcohol, and blood-thinning medications for 24 hours before the procedure.
- Do not apply any skincare products on the eyebrow area before the procedure.
If you have any concerns or questions, please contact us before your appointment.

Signature: Signature Date: Date

Name: First Name Last Name
Should be Empty:

Microblading and Shading Consent Form

**Please read and initial each statement:**

**Medical History Questionnaire:**

Please read and initial each statement:

Medical History Questionnaire: