Name
*
First Name
Last Name
E-mail Address
*
Mobile Phone Number
*
Landline Phone Number (if applicable)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Date of Birth
*
Please read these statements carefully - Permanent cosmetics are a form of tattooing. - Re touch procedures may be required. - A healing period of 4 to 6 weeks is required before any touch-up procedure can be performed. - On rare occasions the pigment may migrate under the skin. - Application of permanent cosmetics can be uncomfortable. - The pigments will fade. - Immediately after the procedure, the pigment can be 30 to 50% darker than the desired result. - There may be immediate or delayed allergic reaction to pigments. However, allergic reactions are extremely rare. - A negative allergy test result will not guarantee that you will not have an allergic reaction. - Infections can occur if aftercare is not followed. - Allergic reactions to anaesthetics can occur. - There may be swelling and redness following the procedure. - You may experience minor bleeding. - If you have a MRI scan within 3 months your permanent cosmetics procedure we recommend that you discuss this with your doctor. This information is not intended to alarm you. However, it is imperative that you are informed of the risks involved.
*
I have read and understand the above statement
Eyebrow Photos
Please take a close up photo of each of the views requested below and upload them in the appropriate file upload
Close up front view of both brows
*
Upload a File
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Close up of right brow
*
Upload a File
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of
Close up of left brow
*
Upload a File
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of
Full facial to show the shape of your face
*
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Microblading Treatment Required
Please choose the type of treatment required
Please select the option the best describes the microblading treatment required
*
Fully Reconstruct
Define Existing Brows
Make Existing Brow Bigger
Other
Medical Information
Name of Doctor
Surgery Name
*
Surgery Phone Number
*
Surgery Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list all the medication taken within the last 6 months
Have you taken any of the following in the last 48 hours?
*
Rows
Yes
No
Aspirin
1
2
Ibuprofen
3
4
Coumandin
5
6
Alcohol
7
8
Have you ever had an allergic reaction to any of the following:
*
Rows
Yes
No
Anaesthetics
9
10
Adrenaline
11
12
Latex Rubber
13
14
Vaseline
15
16
Crayons
17
18
Metals
19
20
Drugs
21
22
Paints
23
24
Lanolin
25
26
Foods
27
28
Medication
29
30
Glycerine
31
32
Lidocaine
33
34
Another allergy not listed
35
36
If 'yes' or 'another allergy' please provide additional information below
Have you received chemotherapy or radiation treatment in the last year?
*
Yes
No
Please select yes to the following that apply to you;
*
Rows
Yes
No
Abnormal Heart Condition
37
38
Cold Sores (herpes simplex)
39
40
Mitral Valve Prolapse
41
42
Heart Murmur
43
44
Rheumatic Fever
45
46
Pacemaker
47
48
Artificial Heart Valves
49
50
Anaemia
51
52
Haemophilia
53
54
Prolonged Bleeding
55
56
High Blood Pressure
57
58
Low Blood Pressure
59
60
Circulatory Problems
61
62
Diabetes
63
64
Epilepsy
65
66
Fainting Spells or Dizziness
67
68
Thyroid Disturbances
69
70
Liver Disease
71
72
Kidney Disease
73
74
Glaucoma
75
76
Stomach Ulcers
77
78
Tumours, Growths or Cysts
79
80
Cancer
81
82
Tuberculosis
83
84
Stroke
85
86
HIV
87
88
Prosthetic Hip or Joint
89
90
Palpitations
91
92
Hepatitis
93
94
Cataracts
95
96
Blurred Vision
97
98
Dry Eyes
99
100
Eye Infection present
101
102
Alopecia
103
104
Recent Hair Loss
105
106
Watery Eyes
107
108
Contact Lenses
109
110
Eyelid Surgery
111
112
Chapped Lips
113
114
Trichollomania
115
116
Gore-Tex Implants/Silicone Injections
117
118
Fat Transfer Injections
119
120
Botox Injections
121
122
Collagen Injections
123
124
Hypertrophic Scars
125
126
Keloid Scars
127
128
Scar Easily
129
130
Healing Problems
131
132
Bruise or Bleed Easily
133
134
Sensitivity to Cosmetics
135
136
Use of Sun bed
137
138
Acutance within 6 months
139
140
Cortisone within 6 months
141
142
Chemical or laser peel within 6 months
143
144
Retin A within 6 months
145
146
AHA preparations within last 2 weeks
147
148
General Consent & Procedure Permit
1. I hereby authorise
[enter technician's name]
(microblading technician) 2. Of [enter company name] to perform the microblading/ombre brow treatment upon myself. If any unforeseen condition arises in the course of this procedure(s), calling in their judgement in addition to, or different from those now contemplated, I further request and authorise the technician to do whatever they deems advisable and necessary in the circumstances. 3. I accept responsibility for determining the colour, shape and position of the permanent cosmetic procedure as agreed during the course of my consultation. 4. I understand that an allergy test does not guarantee that I will not have an allergic reaction to the pigment. I confirm I have completed a patch test for this procedure, within 6 months of the treatment date. 5. I fully understand and accept that non-toxic pigments are used during the procedure and that the cosmetic enhancement achieved may fade in between 1-3 years. 6. I have been informed that the highest standards of hygiene are met, and that sterile disposable needles, and pigment containers are used for each individual client, procedure and visit. 7. I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desirable results and that 100% success cannot be guaranteed. I understand this is why I need to return for a retouch procedure. 8. I understand that a retouch procedure will be performed 1-3 months after the initial procedure and after a 3-month period I will be charged an additional fee for any further work. I will book the appointment when it is convenient for both parties. 9. The result of the procedure is determined by the following: - Medication - Skin Characteristics - (dry, oily, sun-damaged and thickness) - Natural skin undertones - (blending with chosen pigment) - Personal pH balance of skin, which changes from visit to visit - Alcohol intake and smoking - Post procedure care treatment 10. Upon completion of the procedure there may be swelling and redness of the skin, which will subside in 1-4 days. In some cases bruising can occur. You may resume normal activities immediately following the procedure, however, using cosmetics, excessive perspiration wetting and exposure to the sun on the affected area should be limited. See specific post-procedure instructions for details. You can however, be assured the procedure, even after only one treatment, looks acceptable and you should feel comfortable appearing in public without additional makeup on the affected area. 11. I have been advised that the true colour will be seen 1 month after each procedure, and that the pigment may vary in colour according to skin tones, skin type, age and skin conditions. I understand that some skins except pigment more readily than others and no guarantee to an exact effect or colour can be given. 12. I am aware that the lip procedures may stimulate any dormant virus such as herpes (cold sores). I am informed that eye procedures may stimulate dormant eye disorders or eye infections, and that some medication can prevent absorption of the pigment. 13. To my knowledge I do not have any physical, mental, or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I am at least 18 years old. I am not under the influence of drugs or alcohol, pregnant or breastfeeding. 14. I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. 15. Being of sound mind and body, I hereby release any and all responsibility. I accept any and all responsibility myself for any consequence that might stem from my decision to have any permanent cosmetics procedure performed by
[enter technician's name]
(microblading technician) 16. For the purpose of documentation, I also consent to the taking of “before” and “after” photographs of the microblading procedure(s)
*
I have read and understand the above information
Topical Anaesthetic Form
Allergic Reaction– Allergic reaction can occur from any anaesthetics used during the procedure. If you do suffer from an allergic reaction you should contact your doctor immediately. Allergic reaction response may display redness, itching, swelling, a rash, blistering, dryness or any other symptom associated with allergy. Numbness - We cannot accept responsibility if the treatment area does not numb. Each individual is different according to the skin type. Some clients have reported that the area is totally numb while others say they experience some discomfort. Procedure – For all procedures a cream or gel topical anaesthetic is used. These products are perfectly safe, and can be purchased over the counter from any chemist. The anaesthetic is placed over the treatment area for between twenty to thirty minutes then carefully removed prior to treatment. Please be aware that you may experience swelling and redness that can last between one and four days. You should always follow your post procedure instructions.
*
I have read and understand the above information
Authorised Use Only
Skin Type
Pigment Colour
Consultation Date:
Treatment Date:
Top-Up Date:
Location
Treatment Price
Top Up Price
149
Rows
Date Completed
Skin patch test
Pre instructions
After Care instructions
Before photos
After photos
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