Microblading Release and Medical Form
Name: ________________________________
Today’s Date: ___________________ Birth Date: __________________ [guest must be 18+ years old]
Address: _____________________________________________________
___________________________________________________________
Phone Number: _________________________________
Emergency Contact Name & Phone: __________________________
What Microblading (micropigmentation) is:
Also referred to as semi permanent makeup or Microblading is a process where pigments are implanted into the epidermis (top layer of skin). It involves drawing individual strokes that are more natural looking than tattooing. The needles that are used for this technique are three times thinner than needles used for tattooing. It was first introduced in Asia. This technique has been medically developed and specifically designed for a safe semi permanent application. Permanent cosmetics is a safe and natural-looking alternative to the expense and daily routine of applying makeup. The medical grade pigments used have been specially formulated for this kind of procedure. Technicians use a numbing solution to limit discomfort.
Microblading is not recommended to the following guests:
List all medications you are currently taking, including Retin A, Glycolic Acid and Accutane:
_________________________________________________________________
_________________________________________________________________
List any drug, makeup, skin and food allergies (i.e., soaps or cleansing creams):
_________________________________________________________________
_________________________________________________________________
Please select skin type:
____Normal
____Dry
____Oily
____Combination
**Please note, oily skin is not recommended for microblading. Strokes will not heal clean and crisp.
Do you have or have you had any of the following conditions (check off if Yes):
____Keloid Scarring
____Abnomal Heart Condition ____Dry Eye
____Cold Sores ____Corneal Abrasions
____Herpes Simplex ____Eye Surgery or Injury
____Hemophilia ____Visual Disturbances
____High or Low Blood Pressure ____Blepharoplasty (eyelid surgery)
____Prolonged Bleeding ____Cancer ____Chemotherapy/Radiation ____Epilepsy
____Diabetes ____Are you pregnant?
____Fainting Spells/Dizziness ____Hepatitis
____Cataracts ____Do you wear contact lenses?
____Glaucoma ____Do you use tobacco products?
____Are you using any eye drops or other ocular medications?
____Have you ever experienced hyper-pigmentation from an injury?
When was your last eye exam? ____________
Please initial for the following:
____I have been told a follow up procedure will be required after 30-60 days from receiving the original service for no additional cost.
____I understand that there is a possibility of keloiding of the skin occurring.
____I have been told that allergic reactions to pigment are very rare, however, they can and do occur and when they occur they can be serious and especially difficult and very troublesome to treat.
____I have been told that this procedure can involve pain and discomfort.
____I understand the markings are semi-permanent and there is a possibility of hyperpigmentation resulting from a procedure, especially for individuals prone to hyperpigmentation from a scar or other injury.
____Other risks involved with the procedure may include, but not limited to: infections, allergic and other reactions to applied pigments, allergic and other reactions to products applied during and after the procedure, fanning or spreading of pigment (pigment migration), fading of color and other unknown risks.
____I accept full responsibility for any and all , present and future, medical treatments and expenses I may incur in the event I need to seek treatment for any known or unknown reason associated with the procedure planned for me.
____I have agreed that should I have a complaint of any kind whatsoever, I shall immediately notify the artist and I further agree that any controversy or claim arising out of or relating to this consent and/or signed contacted between myself and the artist the breach thereof, shall be settled by arbitration in the state of in accordance with the Rules of the American Arbitration Association and judgement of the award rendered by the arbitrator may be entered in any court having jurisdiction thereof.
____I understand that if I have an infection, adverse reaction or allergic reaction to the procedure, I must notify the artist and, a health care practitioner
____I certify this form has been fully explained to me and I have read it or it has been read to me. I understand its contents.
____I have received a copy of the Post Procedure Instructions. It has been fully explained to me and I have read it or it has been read to me. I understand its contents.
____I understand the procedure I am receiving and that all Brow Embroidery are final and will not be refunded.
____I have been given an opportunity to ask questions about the procedures and the procedure to be used and the risk and hazards involved and I believe that I have sufficient information to give informed consent.
I, ____________________________, as a client have request that you describe the procedure to be utilized so that I may make an informed decision whether or not to undergo the procedure.The artist has described and recommended the procedure to use Micro Pigment Implantation, the process of implanting micro insertions of pigment into the dermal layer of the skin. Micro Pigment Implantation is a form of tattooing used for the purpose of permanent/semi permanent makeup and skin imperfection camouflage/enhancement.
Signature: __________________________________________ Date: ______________________