Permanent Makeup Consultation Form

Consultation Form
CLIENT INFORMATION
Name*

First NameLast Name
Age
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Company Name
Procedure/Service Desired

MicrobladingShadingOmbreCombinationTouch-upColor CorrectionTo be Decided/Advised
GENERAL MEDICAL INFORMATION

(Important. Required to determine eligibility for service)

Do you have? (check all that apply)*

	Yes	Note
Fever Blisters/Cold Sores (ever, even one time)
Glaucoma or other eye disease/disorder
Grave's Disease
Heart Disease
Mitral Valve Prolapse
Valve Implants
Pecemaker
Stents
Diabetes requiring insulin
Problems with healing
Keloids
Seizures
Dermatological Disorder (Please scribe). Active or in Flare-ups?
Hemophilia or Clotting Disorder
Autoimmune Disorder
Pre-existing nerve damage
Tatoos. Colors you are sun sensitive to?
Trichotilomania (pulling of hair, brows, lashes)
Alopecia Totalis or Areata
Allergies(If yes, please list)
NONE OF THE ABOVE

Are you? (check all that apply)*

	Yes	Note
Pregnant
Planning cosmetic surgery. If so , what & when?
Currently under the care of a physician. Please describe
NONE OF THE ABOVE

Do you use? (check all that apply)*

	Yes	Note
Acutance (currently or within the past year)
Antibiotics prior to dental procedures
Sterids
Retin-A, Glycolic Acid, Vitamin C or other Exfoliants
Tanning beds
Eyebrows Tinting
Eyelash Tinting
Lattisse
Botox. When?
Chemical Peels. When?
Chemotherapy or Prophylactic does of Chemotherapy
Blood Thinners
NONE OF THE ABOVE

Have you had? (check all that apply)*

	Yes	Note
Permanent Make-up (on brows only) before? When?
Fever Blister/Cold Sores (ever, even once)
Eye Infections (Are you prone to them)
Vision Correction Procedure (Lasik, RK) within the past 3 months
Heat Attack - When?
Joint Replacement, Organ Transplant
Eye Trauma
Seizures
Fainting Spells
Hepatitis Test - When?
Fat Transfer Injections - If yes, where?
Gore- Tex Implants - If yes, where?
Aesthetic or Cosmetic Procedures. If yes, where?
Laser Treatments. What type & why?
NONE OF THE ABOVE

Do you practice outdoor activities? (check all that apply)

	Yes
Tennis
Golf
Gardening
Swimming
Skiing
Walking
Running

Your Physician's Name:   First Name   Last Name
Address:   Street Address   Address Line 2   City   State   Zip
Phone:   Area Code   Phone Number
Specialty:
Please upload a few pictures of your brows, including one that shows your full face.*

Cancelof
I understand that during subsequent visits it is my responsibility to inform the technician of any updates to the answers I have provided on this form.

I certify that the information above is true & correct and I have not withheld any information requested on this form. I understand that it is my responsibility to inform the technician of any medical or health conditions, as they may affect my treatment. Failure to answer truthfully may result in personal injury. My signature below constitutes my consent to treatment. I hereby give my consent and authorization voluntarily. I release this establishment and its agents from liability for any injury, loss or damage that may result from any information I have withheld.
Signature*
Type your Full Name.
PERMANENT MAKE-UP BASIC INFORMATION

Please read carefully and sign
Depending on the skin structure, after the first treatment, small flakes with a loss of some pigment may occur and color intensity may change. Treatments require one or several Touch-Up sessions to achieve optimal results. In the first seven days brows are up to 40% darker and 10-15% thicker than the healed results. This will subside and look more natural once fully healed. The final result cannot be determined until brows are completely healed, around 6 - 8 weeks. Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-2 days. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be avoided until the skin has fully healed. The procedure results will look acceptable to appear in public without additional make-up on or around the brows. I agree to follow the After Care Instructions provided perfectly in order to ensure my satisfaction with the final results. I understand that my technician will be taking photographs before and after the treatment for record keeping and liability purposes and that this is necessary if I am to undergo the procedure. These photos may be shared on Lash Perfect social media accounts and if I wish to remain anonymous I have the right to request my identity be hidden (close-up of brows & eyes only.)

Microblading/Shading/Powder/Ombre/Combination Brows are forms of tattooing. We are implanting pigment (ink) below the surface of the skin with a manual tool or machine. There may be risks associated with this procedure.
The treatment is semi-permanent and may fade over time and it is necessary to have the color refreshed after a while. If you are returning with strokes and shape still visible, it is considered a “Refresh.”
Those with oily skin may need to return sooner for refreshing (between 6-8 months for Microblading and even sooner for Nano Hairstrokes.) For this reason, the Powder Brow is the preferred technique for oily skin. It will last longer and age better than Microblading for this skin type.
Semi-Permanent Brows require at least 2 sessions. For best results, clients are highly recommended to return for a re-touch appointment. This will take place 6-8 weeks after the initial procedure and is NOT included in the cost. Please be aware that color intensity will be significantly darker and sharper immediately and for a few days after the initial procedure, but the color will reduce by about 40%.

Although a topical anesthetic is used during the procedure, sensitivity or discomfort may still be felt. Skin may be red and/or swollen after the procedure.
Please do not drink alcohol 24 hours prior to the treatment, or caffeine the day of the treatment. Please refrain from exercise the day of the treatment. All of these can increase blood flow in the body and this can cause excessive bleeding. If there is excess bleeding during treatment we may not be able to finish the procedure. Unless medically necessary, please avoid taking things that thin the blood like fish oils, herbals, Vitamin E, aspirin.

Please do not shape or wax your brows for at least 2 weeks prior to the procedure.
AHA products and retinoids should be avoided for 2 weeks prior to the procedure (resurfacing or anti-aging products generally contain these ingredients.) Botox and Fillers may not be used within 2 weeks before/after treatment either. Exfoliating treatments such as microdermabrasion should not be performed within 2 weeks prior to procedure. Chemical and laser peels should be avoided no less than 6 weeks prior to procedure.

Hormone therapies can affect pigmentation and/or cause sensitivity.
Discontinue use of any brow-growth serums like Latisse, as it can cause sensitivity and affect pigment.

The following medical conditions require a note from your doctor giving consent: Diabetes, Auto-Immune disease, and any other medical condition that causes slow healing or a high risk of infection. It is possible that certain medications and pre-existing health conditions may interfere with the healing process or put you at increased risk of complications, this is why a consultation with a health professional before receiving a body art service is necessary.
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Type your Full Name.
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Consultation Form

CLIENT INFORMATION

GENERAL MEDICAL INFORMATION

PERMANENT MAKE-UP BASIC INFORMATION