Permanent Makeup Consultation Form

Permanent Makeup Consultation Form

Nano Brows/ Powder Brows/ Combo Brows
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Company Name
Procedure/Service

Other
Are you currently taking any medications?
What are the medications you're currently taking and what is their purpose?
Do you have any allergies?
Please list down your allergies below (e.g. seafood allergy, penicillin-based antibiotic allergies)
Are you pregnant?
Are you breastfeeding?
Are you wearing contact lenses?
Do you have any implants?
Do you have any Botox or other injectables?
Do you participate in outdoor recreational activities?

Please check below if you have the following medical condition:

Rows	Yes	No	Remarks
Cancer
Hyperpigmentation
Keloid
Hemophilia
Diabetes
Hepatitis
Tuberculosis
Epilepsy
Anemia
HIV positive
Cancer
Venereal Disease
Asthma
Iron Deficiency Anemia
Radiation therapy or chemotherapy
Eye Disorder
Skin Disorder
Herpes Simplex
Alopecia

Have you had micropigmentation before?
When did you have it?

MonthDayYear
Date
Please upload a photo of your current brows

Cancelof
How did you hear about us?

Other
Acknowledgment

CLIENT CONSENT FORM
Check the box
By signing below I agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of anychanges in the above information. I agree that do not have any condition(s) that would make the requestedtreatment unsuitable. I will inform the technician of any discomfort I may experience at any time during mytreatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and thesalon for any injuiry or damages incurred due to any misrepresentation of my health.This agreement will remain in effect for this procedure and all future follow-ups conducted by the technician. Iunderstand that this consent agreement is legal and binding. I have read and fully understand all informationin this agreement. I am over 18 years of age and consent to the agreement and to the brow laminationprocedure, or if I am under 18 years of age, I have had my parent or legal guardian consent to this agreement,and his or her relationship to me is as follows:By his or her signature below, he or she ratifies and consents to this procedure under these terms.
Signature
Date

MonthDayYear
Date

PRE-CARE INSTRUCTIONS

Eyebrows
- No alcohol for at least 24 hours before the procedure.
- No caffeine on the day of the procedure.
- No blood thinners including pain killers for at least 24 hours before the procedure.
- No aspirin, ibuprofen or aleve for at least 48 hours before the procedure.
- No working out on the day of the procedure.
- No sauna or tanning 1 week prior.
- You cannot be pregnant or breastfeeding.
- Discontinue use of fish oil or vitamin E at least one week prior.
- No botox injections in the brow area for at least 2 weeks prior to the procedure.
- No deep exfoliation in the brow area for at least 2 weeks prior to the procedure
- No retinol products, acne treatments or salicylic acid in the brow area for at least 4 weeks prior.
- No antibiotics at the time of your appointment.
- No eyebrow tinting 2 weeks prior to the procedure.
- A patch test will be performed prior to the procedure unless waived.
- Any waxing should be performed at least 48 hours before the procedure:
- Electrolysis no less than five days before the procedure.
- Please wear your normal makeup to the salon on the day of the procedure.
- Since delicate skin or sensitive areas may be swollen or red, it is advised not to make social plans for the same day.
WHAT TO EXPECT
Immediately the days following your procedure, the tattooed area will appear to be darker and bolder in color and more sharply defined. The complete healing process takes about 6-8 weeks, at which time the true color of the tattoo is evident. During this process, your tattoo will soften and lighten. Be patient and wait at least 6 weeks to see the true color.

AFTER-CARE INSTRUCTIONS

EYEBROWS
Day of:
- After the procedure, gently blot the area with a clean tissue to absorb excess lymph fluid. Do this until the oozing has stopped.
- Days 1-7 (wash & moisturize):
- Gently wash the area each morning and night with water and gentle soap or an unscented cleanser. With a very light touch, use your fingertips to gently cleanse the area.
- After each wash it is very important to let the brows dry completely before you add moisturizer.
- To dry, gently pat with a clean tissue. DO NOT use any cleansing products containing acids (glycolic, lactic, or AHA), or exfoliants.
- When dry, use a sterile Q-tip and GENTLY dab (DO NOT RUB) the balm provided onto your brows using an amount equivalent to the size of half a grain of rice for each brow. (If you use the correct amount you will not see a glossy look on your brows.
- Day 5-12 (peeling/flaking phase):
- Once this process begins you can discontinue washing and keep moisturizing your brows. Do not pick, and allow the scab or dry skin to come off on its own.
- DO NOT sleep on your face, please try everything possible to refrain from rolling on to your face in your sleep.
- When your brows are no longer flaky (typically between day 10-14) this phase of healing is complete and you can resume regular activities. You will still want to avoid all products on them that include active ingredients (acne or anti aging products, salicylic acid, etc)and protect your fresh brows from UV exposure.
Should be Empty: