Please answer the questions below truthfully to the best of your abilities, this information is crucial as it tells me if you are a viable canidate for permenent makeup.

The information in this form is confidential to Aubrey Pilachowski Only. By signing, you are stating that all of the information you provided is accurate and true to the best of your knowledge.

Please circle your current brow shape.

Please read the following in it's entirety. This form was created to make you aware of the potential risks that follow with undergoing the Permanent Makeup and to give you the information you need to assure this is the right service for you.
If you have any questions or concerns, please don't hesitate to express them to me.

Please INITIAL each line below to ensure you have read and understand this form in it's entirety.

Although permanent makeup effective in most cases, there is no guarantee that can be made that a specific client will benefit from the procedure. This is a process of inserting pigment into the dermal layer of the skin (the first layer), and every person's skin is different and reacts/holds to the pigment differently. Even if you fit all the criteria for this procedure, there is always the chance that your body rejects the pigment, or that you bleed too excessively to perform/finish the procedure. Bleeding too much can affect the pigment intake and make you prone to forming more scar tissue, which can greatly influence the integrity, duration and quality of your brows.

Generally, the results are wonderful and improper healing is rare. However, it is normal to notice some strokes fade or even disappear. That is why your 6 week touch-up is crucial for the desired results and longevity of the pigment.. You'll then return 1-2 times a year for an annual color boost.

Your brows will be very dark and intense the first 5-7 days, this is a part of the healing process where the pigment has not yet settled into the skin. After those 5-7 days, the flaking will start and it may appear that the strokes/pigment underneath have disappeared. This is normal, the ink will resurface to the top layer of the skin within a few days. The flaking period should be light flakes of dry skin with color to it, no rough scabs. The more moisture in the brows = more scabbing, which jeopardizes the healed results. Your aftercare routine is VERY important for proper healing!

All instruments that enter and/or touch the skin, or come in contact with bodily fluids are removed from a sterile sealed pouch and get disposed of immediately after use. Proper sanitation and cross-contamination guidelines are strictly adhered to.

I understand that the success of my nano, powder or combo brow results requires my careful consideration, proper after-care and maintenance. I understand that I must strictly adhere to all after-care instructions, and failure to do so can result in an undesired finished product or infection. I acknowledge that I cannot hold Divine Eyes and Brows or my Practitioner responsible for any possible complications that could arise due to inept after-care or unprovided medical information on my end.

I have been informed of and acknowledge that Divine Eyes and Brows requires a booking fee for all appointments to cover any last minute cancellations or no shows, and said booking fee can be transferred for rescheduled appointments at the artists discretion but is non-refundable for cancellations or no-shows. I have read the policies form provided to me and will abide by my practitioner and business policies. Failure to do so can result in your practitioner refusing or stopping your service.

By signing below, you are agreeing to Divine Eyes and Brows taking and using before, during and after photos/videos of the process of your appointment for insurance and marketing purposes. Examples would be; in portfolios, social media, in-print ads, marketing fliers/email's etc. Your consent is necessary regarding this. Please circle whether or not you wish to give us consent for your photos to be used in marketing.

Please INITIAL and sign below to ensure you have read and understand the possible risks and important information provided.

Pain: There is a topical anesthetic applied before we start the procedure and a secondary anesthetic before the second pass of strokes is done. Once the anesthetic is applied, there is still a possibility of painful sensation. The anesthetic works better for some and less for others. Please let me know if you are allergic to any anesthetics like lidocaine, prilocaine, benzocaine, tetracaine or epinephrine in the form of gel or cream.

Infection: Infection is very rare and only occurs if the brows are improperly cared for during the healing stage. Your hands should always be washed before touching the brow and brow area, and the brows should be kept dry at all times during healing only for the exception of washing them.

Uneven pigmentation/asymmetry: Lost or faded pigmentation is normal before the first touch-up, and the pigment disappearing and resurfacing again during the healing is normal. However, uneven pigmentation can occur from improper care during healing, excessive bleeding or an allergic/severe reaction to the product. No brows are perfectly symmetrical. They are sisters, not twins. I get them as symmetrical to each other as I possibly can, but understand that there are many reasons for asymmetrical brows and you may notice very tiny differences in spacing or symmetry upon close-up inspection.

Excessive swelling, bruising or bleeding: Some people bruise and have a little bit of swelling and even bleeding. That can be soothed with an ice pack. However if you ever notice physical symptoms of infection, severe swelling or bruising or excessive bleeding, immediately consult your physician.

MRI: Because pigments are used in permanent cosmetic procedures, they contain inert oxides, and a low level magnet may be required if you have to get scanned by an MRI machine. You must inform your physician of any tattoos or permanent cosmetics.

Allergic reactions: It is always possible to develop an allergic reaction to any of the products used during the procedure. A patch test will be performed at the consultation 3-8 weeks before the procedure.

I was provided an extensive permanent makeup after-care guide by my technician and I have read it thoroughly. I understand that I will have to abide by this routine and attend the 6 week touch up to achieve the desired finished look.

My technician has gone over and informed me of the possible risks, hazards, what the microblading procedure entails, and has consulted with me on my desired shape, style, pigment and price range.

I understand that I am not legally required to provide accurate or true information regarding my medical history, but I do acknowledge that failure to provide accurate or true medical history/information can result in an allergic reaction, infection, poor pigment intake, and/or any current medications to possibly interfere with the pigments.

I acknowledge and release Aubrey Pilachowski from the responsibility of any pre-existing medical conditions or diseases that I have not yet revealed, or any consequential changes to those conditions that arise subsequent to the procedure. I understand that I am responsible for any medical treatment I may need as a result of getting this procedure. I understand that I cannot hold Divine Eyes and Brows accountable for any complications that may arise as a result during or following the microblading procedure if I was properly instructed by my practitioner, and I accept all responsibility for these possibilities if they are to occur.

I, herein signed in the 'release form' provided, release, give up, acquit and discharge my practitioner and/or anyone affiliated with Divine Eyes and Brows for any claims or damages of any nature. I agree to pay any costs of legal services necessary to further affect or confirm said release. I further agree that this release shall be in contemplation of any possible damages, either known or unknown at the time of signing this waiver, and said damages are specifically waived following the signing of the waiver. I further agree to hold Aubrey Pilachowski nameless and harmless from any and all damages, discrimination or defamation.

Please sign below to ensure you have read and understand the possible risks and important information provided.

I certify by signing that I have read, or have had read to me by my practitioner, the contents of this 'statement of consent/release form' and the aftercare instructions/expectations.

I understand and accept all of the possible risks and complications from the procedure and hereby acknowledge that I am solely responsible for my decision to undergo the 3D Eyebrow Embroidery procedure in this matter.

I further accept, acknowledge and certify that by initialling the statements in the form previously provided and by signing below, that I am not able to hold my practitioner, Aubrey Pilachowski, accountable or responsible for any possible complications or unforeseen obstacles that could affect my microblading healing process.

By signing, I also accept and understand that I am unable to hold my practitioner, Aubrey Pilachowski, or Divine Eyes and Brows financially accountable or responsible for the cost of any medical related needs if I were to need medical attention/treatment as a result of the microblading procedure.

Lastly, by signing, I understand that my practitioner has gone over and consulted with me on the payment expected at the day of my permenant makeup procedure, that includes the cost of the service and booking fee. I further understand that by signing I agree to pay the cost of my services, and continuous failure or refusal to do so will result in forbidding or denying future services and the possibility of a court-mandated payment.