Microblading Consultation/Consent Form | Beauty Forms Portal

Microblading Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical Information

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Health Information

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for microblading and must be disclosed and discussed with the specialist prior to treatment.

Please check all that apply and give details below:

Liver disease Pregnancy Breastfeeding Compromised skin near brow area Chemotherapy / Radiation Diabetes Type 1 or Type 2 High blood pressure Auto-immune disease Thyroid / Graves’ disease Any medical condition that causes slow healing or a high risk of infection

If you have ticked any of the above contraindications please give details:

Do you have any other medical conditions? *

Please specify: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relationship: *

Pre Procedure Advice

The microblading procedure normally requires multiple treatment sessions. For best results, clients will be required to return for at least one re-touch appointment - this will take place 4-6 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 and a few days after the initial procedure but the color will reduce by 30-50%.
Although numbing cream is used during the procedure sensitivity or discomfort may still be felt. Skin may be red and/or swollen after the procedure.
Please wear your normal make up on the day of your procedure.
Please DO NOT drink alcohol 24 hours prior to the treatment.
Where possible try to avoid the following herbs and spices prior to your appointment: Black pepper, Cardamom, Any member of the Zingiberaceae (Ginger) family, Cayenne, Cinnamon, Garlic, Horseradish, Mustard.
There is no need to shape or wax your brows before the procedure. Your technician will shape your brows during the procedure.
No electrolysis for at least 5 days before the procedure.
Botulinum Toxin (Botox), AHA products and Retinoids should be avoided for 2 weeks prior to the procedure.
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.
Patients prone to cold sores/fever blisters should take an antiviral prior to treatment.
Hormone therapies can affect pigmentation and/or cause sensitivity.

Post Procedure Advice

Please follow these instructions for 10-14 days after the procedure to improve and prolong the results. If you don’t follow these instructions, it could greatly affect your microblading results.

Avoid getting anything on the brows, including water, except for cleansing as directed. You may blot for the first few hours with sterile gauze to remove any excess fluids if necessary.
Cleansing: 2-3 hours after the procedure, wash lightly with slightly damp Q-tips and antibacterial or green soap (non-scented orange Dial soap is a great option). Repeat this very gently during days 1-4. When washing it should be very gentle and with hardly any water.
Do not attempt to remove the barrier film if it was applied - allow it to come off naturally in its own time. Please avoid saturating brows with water. After the initial 3 days of washing you may very sparingly apply balm to hydrate your brow area for dryness relief.
Do not pick scratch or rub the brows. The flakes must fall off on their own or you will risk removing the color and possibly scarring. You may tap them to alleviate any itch.
Do not soak the treated area in the bath pool or hot tub. For 30 days refrain from swimming in salt water or chlorinated pools, saunas, hot yoga, steam rooms or sun beds.
No exercise for 14 days. After 14 days – when exercising, wear a sweatband to avoid sweat on brow area.
Do not expose treated area to direct sunlight. After healed (30 days) use a sunscreen to avoid fading from the sun.
No makeup should be applied directly on the brows during the healing process.
If your eyebrows get wet during the healing process pat them dry with a towel - DO NOT RUB.
Avoid using daily skincare products directly on the eyebrows.
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.

Topical Anaesthetic Advice

Allergic reactions can occur from any anaesthetics used during the procedure. If you do suffer 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 anaesthetic 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 anaesthetic, 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.

Consent

Consent Statements

Please check each box to show your understanding and agreement:
I am over the age of 18.	.
I am not under the influence of drugs or alcohol.	.
I am not pregnant or nursing.	.
I desire to receive the indicated semi-permanent pigmentation procedure.	.
The general nature of cosmetic micropigmentation as well as the specific procedure to be performed has been explained to me.	.
If an unforeseen condition arises in the course of the procedure I authorize my therapist 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 1-3 years. Even once the color fades pigment itself may stay in the skin indefinitely.	.
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 instructions for more details.	.
I have been advised that the true color will be seen 4-6 weeks 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.	.
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 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 accept full responsibility for the decision to have this cosmetic semi-permanent pigmentation work done.	.
I give the therapist permission to perform my microblading procedure.	.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Tap or click on the signature above to sign

Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to your sense of smell or taste
shortness of breath
feeling tired or exhausted
an aching body
a headache
a sore throat
a blocked or runny nose
loss of appetite
diarrhoea
feeling sick or being sick