CLIENT CONSULTATION AND MEDICAL HEALTH FORM FOR MICROBLADING

           

Name:                                                              DOB:                        Best Phone Contact:                                                   

Address:                                                                                    Email:                                                                                 

List any medications you have been taking in the past 6 months:                                                                                        

Have you received chemotherapy or radiation in the past year?                                               

Have you ever had an allergic reaction to any of the following (please circle):

Latex                      Lanolin                  Vaseline                Medication                            Metals                    Hair Dyes

Foods                     Lidocaine              Paints                     Crayons                                 Glycerin  

Have you ever had one of the following (please circle):

Retin-A in last 2 wks

Anemia

Sensitivity to cosmetics

Prolonged bleeding

Diabetes

Trichotillomania

Epilepsy

Artificial Heart Valve

Low Blood pressure

High Blood Pressure

Hemophilia

HIV

Fainting spells or dizziness

Circulatory Problems

Hypertrophic scars

Liver Disease

Alopecia

Tumors, growths, cysts

Botox/filler injections

Chemical/laser peel in last 6 wks

Thyroid disturbances

Cancer

Keloid scars

Healing problems

AHA’s in last 2 weeks

Hair Loss

Hepatitis

Do you scar easily?

Do you bruise/bleed easily?

Pregnant or nursing?

What are the main concerns relating to your eyebrows?

 

 

 

What would you like to improve about your eyebrows? Consider shape, color, density, thickness… _____________________________________________________________________________________

Are you currently under the care of a physician? If yes, please explain:                                                                     

                                       Physician’s Name                                     

Do you take antibiotics when going to the dentist? If yes, why?                                                                                  

Are you currently taking medication that thins the blood?                                                                                          

Please read the following statements carefully. Microblading is a way of cosmetic tattooing, re-touch procedures may be required. A healing period of 4-6 weeks is required before a touch up procedure can be performed. On a rare occasion, the pigment may migrate under the skin. Procedure of microblading may be slightly uncomfortable. The pigments will fade. Immediately after the procedure, the pigment can appear 30-50% darker than the desired result. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be applied if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after microblading procedure, you should notify/discuss with your doctor. Possible scarring may occur, but is extremely rare.

 

I have received after care information and I’m fully aware of the aftercare procedures.  Yes             No

I fully understand the information provided above & confirm that all info provided by me is correct and truthful.

 

Client’s Name                                                  Client’s signature                                                           Date                    

Technician’s Name                                         Technician’s signature                          

 

 

MICROBLADING PRE PROCEDURE ADVICE

       

 

Please read the following advice carefully and sign at the end

 

•• Microblading procedure normally requires 2 treatment sessions. For best results, clients will be required to return for at least one re-touch appointment. This will take place between 4-8 weeks after the initial procedure. Those with oily skin may require an additional touch up. Please be aware that color intensity will be significantly darker and sharper immediately after the initial procedure and will reduce by 30-50%. 

•• Although numbing cream is used during the procedure, slight sensitivity/discomfort may still be felt by sensitive clients. Delicate or sensitive skin may be red and/or swollen after the procedure.

 

Topical Anesthetic Advice

 

•• Allergic reaction can occur from any anesthetics used during the procedure. If you do suffer from an allergic reaction, you should contact your doctor immediately. Allergic reaction response may show through redness, swelling, rash, blistering, dryness or any other symptoms associated with an allergic reaction.

•• Numbness – We cannot accept responsibility if the area to be treated does not respond to the numbing cream. Each individual is different according to skin type. Some clients report the area to be completely numb, while others may experience some discomfort.

•• Procedure – For microblading procedure, a numbing cream/gel is used. The products are formulated to be perfectly safe and can be purchased over the counter from any pharmacy/chemist. The anesthetic is placed over the treatment area for 20-30 minutes then carefully removed prior to treatment. As a result of the treatment, combined with the use of the anesthetic, you can expect to experience some redness/swelling that can last 1-4 days. You should always follow your post procedure advice and after care for the best results.

 

Contraindications for Microblading

   •• Liver disease – high risk of infection                                                        •• Pregnancy/Nursing

   •• Compromised skin near brow area                                                            •• Chemotherapy/Radiation

   •• Cold sores/fever blisters – please take an anti-viral prior to treatment

•• Hormone therapies – can affect pigmentation and/or cause sensitivity

 

 The following medical conditions require a note from your doctor giving consent

 

**Diabetes Type 1 and 2**, high blood pressure, auto-immune disease, thyroid / Graves’ disease Any other medical condition that causes slow healing or high risk of infection  

 

I have read and full understood the above information provided and any risks involved with the use of topical anesthetic and I therefore consent to the use of the anesthetic for the microblading procedure.

 

I agree to follow pre- and post-procedure advice closely

 

Client Name  

 

 Signature  

 Date                   

Technicians’ Name  

 Signature  

 Date                   

 

 

 

        

 

 

 

Microblading Patient Photo Release Agreement

 

Patient Name                                       

I hereby consent to, and authorize the use by _____________  of the specified microblading photographs and/or video; that is, photographs taken before, during and after my microblading procedure.

 

I understand that my identity will be protected and neither my full face nor my name will be used in conjunction with the photographs and/or video.

 

­­­­­­­­­­­________________has explained that all the photos and/or videos will be clinically appropriate and tastefully presented.

 

I have agreed on the photographs that ___________requests to be used and it is understood that these photos may be used ________________web site, social media accounts (Facebook, Instagram, Twitter), and in-office for demonstrational and promotional purposes. I understand that I am not entitled to compensation for these photos being used.

 

 

Should I desire to revoke permission for their use in the future, I understand that I must notify _________________in writing and allow 30 days to accomplish this removal.

 

I now release_____________, all personal rights and objections I have or may have to the above described uses of my photographs and/or videos. I have entered into this release freely or voluntarily, and agree to be bound thereby.

 

 

 

                                                                                                                                   

     DATE                     PATIENT SIGNATURE         

                                                                                                                                       

      DATE                    TECHNICIAN/WITNESS SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

INFORMED CONSENT FOR MICROBLADING

 

 

I ___________________________________ am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing and desire to receive the indicated semi-permanent pigmentation procedure. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed has been explained to me. The microblading procedure requires 2 visits (in some cases more may be required) and the cost is $_________.

 

Scheduled appointments for the touchup procedure require 48 hour notice for cancellation or rescheduling and are included in the original price ONLY when performed within 12 weeks after the original procedure. Outside 12 weeks or if scheduled appointments are missed, an additional charge will be incurred.

 

» If an unforeseen condition arises in the course of the procedure, I authorize my technician  to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances. I accept the responsibility for determining the color, shape and position of the microblading procedure as agreed during consultation. I fully understand and accept that non-toxic pigments are used during the procedure and that the result achieved may fade over a period of 1-1.5 years

»  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.

» I understand and accept that each procedure is a process requiring multiple applications of pigment to achieve desired results and that 100% success cannot be guaranteed during the first procedure. I understand that I may have to return for a repeated procedure. » The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care.

» Upon completion of the procedure there might be swelling and redness of the skin, which will subside within 1-4 days. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed. Please see after care card for more details. The procedure results will look acceptable for you to appear in public without additional make-up on the brows.

» I have been advised that the true color will be seen 1 month after each procedure, and that the pigment may vary according to skin tones, skin type, age and skin condition. I understand that some skin types accept pigment more readily and no guarantee on exact color can be given.

» 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 agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chances for a successful procedure. I can confirm that I have received a copy of aftercare details.

 

I have been informed of the nature, risks, and possible complications and consequences of permanent skin pigmentation. I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure, including but not limited to: infection, scarring, inconsistent color, and spreading, fanning or fading of pigments. I understand the actual color of the pigment may be modified slightly, due to the tone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science but an art. I request the semi-permanent skin pigmentation procedure(s) and accept the permanence of this procedure as well as the possible complications and consequences of the said procedure ________ (initial) 

I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my microblading procedure. I acknowledge some of these potential adverse changes may not be correctable. ________ (initial).

I agree that reading and signing this consent form, I release all employees of _____________and its owner from any claims or damages of any nature. I agree that I read and fully understand this entire consent form.

 

I certify that I have read and initialed the above paragraphs and have had explained to my understanding the consent and procedure permit. I accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done. 

 

I,                                                             , give _________________ permission to perform my microblading procedure.

 

Client Signature ­­­­­­­­­­­­­­­­­ ­­­­­­­­­­­­­­­­­­­­______________________

DOB____________________  

 

 Date                       

Technician’s Name ______________________

 Signature  _____________

 

 Date                       

 

 

 

 

 

Microblading Aftercare

 

           

Please follow these instructions for 7-10 days after the procedure to improve and prolong the results of  microblading. 

3 DAYS

 

-- DO NOT ALLOW THE BROWS TO GET WET for 3 Days.

You may blot for the first few hours with sterile gauze to remove any excess fluids, if necessary.

 

--Apply the balm provided once a day, very sparingly, with a clean cotton swab until completely healed (5-7 DAYS) to help with dryness. Do not pick or rub the brows. The flakes must fall off on their own or you will risk removing the color and possibly scarring.

 

AFTER 3 DAYS

 

Wash brows gently using a patting motion (not rubbing) once a day with a face wash or antibacterial soap and apply after care product sparingly – only a super light layer is needed. This can be done the night of your procedure and continue daily until healed. Once healed (5-7 DAYS), you may resume usual skin care.

 

  • Do not soak the treated area in the bath, pool or hot tub. Refrain from swimming in salt water or a chlorinated pool until fully healed (30 days). No saunas or hot yoga for 10 days.
  • When exercising, wear a sweatband to avoid sweat on brow area. No exercise for 7 days.
  • Do not expose treated area to direct sunlight. Use a sunscreen to avoid fading from the sun.
  • Avoid touching your brows and be mindful of sleeping on your back until your brows have healed.
  • No makeup should be applied directly on the brows during the healing process.
  • Avoid wetting eyebrows during the healing process .
  • Avoid sauna/steam rooms and sun beds during the healing process.
  • Do not touch, rub, pick or scratch your brows following treatment or during healing process.
  • You may find that your eyebrows will scab or become slightly dry following the treatment.
  • If they itch, DO NO SCRATCH them. Just tap them to alleviate the itch.
  • If your eyebrows get wet during the healing process, pat them dry with a towel, DO NOT RUB.
  • Apply your healing balm according to your therapist’s advice. If you have excessively oily skin, you may not need to use healing balm at all. For those with dry skin, balm can be used up to 3 times a day.
  • A “touch up” session is usually needed 6 weeks after the procedure; please make sure you schedule.
  • Avoid using daily skincare products directly on the eyebrows.
  • If you are having an MRI scan, please inform your doctor that you have had microblading/semi-permanent makeup done.
  • If you are planning a chemical peel, or any other medical procedure, please inform therapist of the procedure you have had. Procedure should only be done once the healing process is complete.
  • If you are due to give blood after the procedure, please inform your nurse about the microblading treatment you have had as this might alter the results.