Published using Google Docs
Brow Release Form
Updated automatically every 5 minutes


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:





**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: ______________________